The nurse is caring for a client in the postanesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the vital signs as a heart rate of 140 beats/minute, respirations 26 breaths/minute, and a blood pressure 140/90 mm Hg. Which intervention is most important for the nurse to implement?

Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.

Medicate for pain and monitor vital signs according to protocol.

Administer intravenous fluid bolus as prescribed by the healthcare provider.

Encourage the client to splint the incision with a pillow to cough and deep breathe.

Answer and Explanation

The Correct Answer is A

A. The elevated heart rate and respirations suggest the client may be experiencing hypoxia, especially following a thoracotomy. Administering oxygen will help improve oxygen saturation levels and address potential respiratory distress.

B. While pain management is essential, the immediate concern is ensuring adequate oxygenation.

C. Administering IV fluids may be necessary but is secondary to ensuring the client's oxygenation.

D. Encouraging the client to splint and cough is important for preventing complications but does not address the immediate issue of vital signs indicating possible respiratory compromise.

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Free Nursing Study Resources

Correct Answer is []

Explanation

Potential Condition:

Rheumatoid arthritis (RA):
- RA is a chronic autoimmune disorder that causes inflammation in the joints, leading to pain, stiffness, and swelling.
- The patient has several classic signs of RA:
  - Pain and stiffness in bilateral hands and wrists: A hallmark of RA, particularly in the morning (worse upon waking).
  - Positive rheumatoid factor and positive antinuclear antibody: Both are commonly seen in RA.
  - Elevated erythrocyte sedimentation rate (ESR): This indicates inflammation, which is typical in RA.
  - X-ray findings of soft tissue swelling and marginal erosions: These are common in RA and suggest joint damage.

Actions to Take:

Educate on disease process and management:
- It’s essential for the nurse to educate the patient on RA, its chronic nature, and the need for lifelong management. This will include medication adherence, managing flare-ups, and joint protection techniques.
Consult dietician for nutrition and weight loss:
- Obesity can exacerbate RA symptoms due to increased joint stress. Encouraging weight loss can help reduce strain on affected joints and improve overall health. A dietician can help with weight management strategies and recommend anti-inflammatory foods.

Parameters to Monitor:

Pain:
- Monitoring pain levels regularly is critical for assessing the effectiveness of treatment and making necessary adjustments to the pain management plan (e.g., the ibuprofen regimen).
Blood glucose:
- Since the patient has a BMI of 31, there is an increased risk for type 2 diabetes mellitus, which is common in patients with RA. Additionally, if the patient is prescribed corticosteroids for RA management, monitoring blood glucose is crucial, as corticosteroids can elevate blood sugar levels

A. Avoid frequent eye pressure measurements. B. Maintain prescribed eye drop regimen. C. Wear prescription glasses. D. Eat a diet high in carotene.

Correct Answer is B

Explanation

A. Avoiding frequent eye pressure measurements is not advisable; monitoring eye pressure is crucial in managing glaucoma.

B. Maintaining the prescribed eye drop regimen is the most important instruction because consistent use of these medications is critical to managing intraocular pressure and preventing vision loss associated with glaucoma.

C. While wearing prescription glasses can assist with vision, it does not address the underlying condition of glaucoma.

D. Eating a diet high in carotene is beneficial for overall eye health but does not directly impact the management of glaucoma. Regular use of prescribed eye drops is essential to prevent further damage to the optic nerve and potential blindness.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

An adult client who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

Correct Answer is B

Explanation

Exhibits The nurse is reviewing the client's dietary choices for opportunities to promote better outcomes by limiting gout attacks. Select the 3 dietary choices that are not part of the recommended diet for a client with gout.

An older adult client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?

Exhibits Client history has been collected, and the nurse performs a physical assessment and records vital signs. Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of compromised peripheral arterial circulation of the lower extremity?

Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, which action(s) should the nurse anticipate? Select all that apply.