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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Correct Answer is B

Explanation

A. A soft diet may not provide sufficient fiber, which is essential for managing diverticulosis and preventing complications such as diverticulitis.

B. A high fiber diet helps to bulk up stool and promotes regular bowel movements, reducing the risk of complications associated with diverticulosis. Increased fluid intake is also essential to help fiber work effectively in the digestive system.

C. While sitting up after meals can aid digestion, it is not a primary dietary instruction for managing diverticulosis.

D. A bland diet may not be necessary; the focus should be on increasing fiber intake rather than avoiding specific flavors or spices unless they cause discomfort.

A. Spinach B. Chicken C. Lentils D. Oranges E. Shrimp F. Liver G. Garlic. H. Sardines

Correct Answer is ["E","F","H"]

Explanation

A. Spinach: Although it contains moderate purine levels, spinach is generally considered safe in moderation for people with gout.

B. Chicken: Lean meats, like chicken, contain moderate purines and are typically allowed in controlled portions.

C. Lentils: While lentils have some purine content, they are generally less likely to trigger gout attacks and can be included in a balanced diet.

D. Oranges: Oranges are low in purines and high in vitamin C, which may help reduce uric acid levels.

E. Shrimp: Seafood, particularly shellfish, is high in purines, which can increase uric acid levels and trigger gout attacks.

F. Liver: Organ meats, such as liver, are rich in purines and should be avoided by individuals with gout, as they can contribute to elevated uric acid levels.

G. Garlic: Garlic is low in purines and is safe for individuals with gout.

H. Sardines: Sardines are also high in purines, making them likely to exacerbate gout by increasing uric acid production.

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Naxlex Comprehensive Predictor Exams

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

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.

Correct Answer is ["E","F","H"]

Explanation

Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure?

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include?

Exhibits The nurse has implemented additional needed actions. Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one answer selected.