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 C

Explanation

A. Obtaining a sample of the drainage is not an immediate priority after evisceration; the patient's safety and stabilization come first.

B. Auscultating the abdomen for bowel sounds is important but secondary to addressing the immediate crisis of evisceration.

C. Preparing the client to return to the operating room is the priority action because evisceration indicates a surgical emergency that requires prompt intervention to repair the abdominal wall and prevent complications.

D. While additional sterile dressing supplies may be needed, addressing the evisceration takes precedence to prevent further injury and manage the patient’s condition.

A. Limit oral fluid intake to 500 mL/day. B. Restrict protein intake by limiting meats and other high protein foods. C. Increase intake of potassium-rich foods, such as bananas or cantaloupe. D. Increase intake of high-fiber foods, such as bran cereal.

Correct Answer is B

Explanation

A. Limiting oral fluid intake may be necessary in some cases of glomerulonephritis, especially if the client is experiencing edema or hypertension, but this is not a universal recommendation and should be assessed individually.

B. Restricting protein intake is important for clients with glomerulonephritis to reduce the workload on the kidneys and prevent further damage. This is a critical dietary adjustment that nurses should emphasize.

C. Increasing potassium-rich foods can be contraindicated in clients with glomerulonephritis, especially if renal function is compromised, as it can lead to hyperkalemia.

D. While high-fiber foods can be beneficial for overall health, they do not directly address the specific dietary needs of a client with glomerulonephritis in terms of protein and electrolyte balance.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?

Correct Answer is B

Explanation

The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?

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?

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?