The nurse is caring for a client who had a bowel resection for colon cancer. The vital signs were stable during surgery. While in the post-anesthesia care unit (PACU) the client is sleepy but awakens easily. The pulse ox is 88%. What would be the priority action by the nurse?
Call a rapid response for more assistance
Administer naloxone 0.4 mg SQ and reassess
Check the temperature and apply warmed blankets
Encourage the client to take deep breaths
The Correct Answer is D
A. Calling a rapid response may be necessary if the client's condition deteriorates, but it is not the immediate priority in this scenario where the client is still able to be aroused.
B. Administering naloxone is appropriate if there is suspicion of opioid overdose; however, the priority is to address the low oxygen saturation first with non-invasive measures.
C. Checking the temperature and applying warmed blankets may be important, but the immediate concern is the low oxygen saturation.
D. Encouraging the client to take deep breaths is the most appropriate immediate action to improve oxygen saturation levels and enhance ventilation, as the client is in a post-anesthesia state where respiratory depression can occur.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["62.5"]
Explanation
To determine the IV pump rate, we need to calculate the flow rate in milliliters per hour (mL/h).
Given:
- Total volume: 500 mL
- Infusion time: 8 hours
Calculation:
- Flow rate = Total volume / Infusion time
- Flow rate = 500 mL / 8 hours
- Flow rate = 62.5 mL/h
Correct Answer is D
Explanation
A. While limiting emesis is important in cancer treatment, combination chemotherapy primarily focuses on improving efficacy and minimizing toxicities, not specifically targeting nausea and vomiting episodes.
B. Combination chemotherapy can actually increase the risk of neutropenia due to the cumulative effects of multiple agents, as each may independently lower white blood cell counts.
C. Decreasing time intervals between remission is not a primary goal of combination chemotherapy; rather, it aims to achieve better overall treatment outcomes.
D. The main rationale for using combination chemotherapy is to broaden the range of cancer cell kill through different mechanisms of action while minimizing the side effects associated with higher doses of a single agent. This approach can improve treatment efficacy and reduce the likelihood of resistance.
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