The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement?
Administer intravenous fluid bolus as prescribed by the healthcare provider.
Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
Medicate for pain and monitor vital signs according to protocol.
Encourage the client to splint the incision with a pillow to cough and deep breathe.
The Correct Answer is B
A. Administer intravenous fluid bolus as prescribed by the healthcare provider.
While hydration is important, the vital signs provided (elevated heart rate and respiratory rate) are more indicative of potential respiratory distress. Administering fluids may be indicated in certain situations, but it may not address the immediate concern of compromised oxygenation.
B. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
This is the correct choice. The client's elevated heart rate and respiratory rate suggest the need for improved oxygenation. Applying oxygen at a high flow rate via a non-rebreather mask is an immediate intervention to address potential respiratory compromise. Monitoring the pulse oximeter provides real-time feedback on oxygen saturation.
C. Medicate for pain and monitor vital signs according to protocol.
Pain management is an important aspect of post-operative care, but the immediate concern in this scenario is the potential for respiratory distress. Administering pain medication alone may not address the primary issue.
D. Encourage the client to splint the incision with a pillow to cough and deep breathe.
While encouraging the client to cough and deep breathe is important for post-thoracotomy care, the elevated vital signs suggest a need for more immediate intervention to ensure adequate oxygenation. Applying oxygen and monitoring the pulse oximeter take precedence.
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Related Questions
Correct Answer is D
Explanation
A. Encourage regular turning:
While turning is important for preventing complications like pressure ulcers, in this acute situation, addressing fluid imbalance and potential sepsis take precedence.
B. Monitor skin for breakdown:
Monitoring for skin breakdown is essential but is not the most critical intervention at this moment.
C. Assess wound drainage daily:
Daily assessment of wound drainage is important for evaluating the status of the surgical site. However, in this situation of potential anastomosis leakage with signs of systemic infection and hypotension, immediate interventions to stabilize the client's condition are of higher priority.
D. Strict IV fluid replacement:
This is the correct answer. The client is displaying signs of systemic infection (fever) and possible sepsis (tachycardia, hypotension), which might be due to an anastomosis leakage following gastric bypass surgery. Ensuring adequate IV fluid replacement is crucial to address hypotension, maintain perfusion, and support hemodynamic stability in this critical situation.
Correct Answer is A
Explanation
A. Prepare the client to return to the operating room:
This is the correct and immediate priority. Evisceration, where internal organs protrude through the surgical incision, is a surgical emergency. Returning the client to the operating room is necessary to assess the extent of the complication, address the wound dehiscence, and protect the exposed organs. This intervention aims to prevent further complications and provide necessary surgical interventions.
B. Obtain a sample of the drainage to send to the lab:
While obtaining samples for laboratory analysis can be important for infection control, in the context of a client with evisceration, the primary concern is the surgical emergency. The priority is to address the wound complication by returning to the operating room rather than focusing on laboratory analysis at this immediate moment.
C. Bring additional sterile dressing supplies to the room:
While bringing additional supplies may be necessary, the priority in this situation is to prepare for the client's return to the operating room. Once the client is in a controlled surgical environment, additional dressing changes and wound care can be performed as needed.
D. Auscultate the abdomen for bowel sound activity:
While monitoring bowel sounds is a routine nursing assessment, in the context of evisceration, the immediate concern is the exposure of internal organs and the risk of infection. Preparing for the operating room takes precedence over routine assessments.
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