A client is on postoperative day 2 after undergoing a total hip replacement.
The client suddenly reports chest pain and is coughing up blood-tinged sputum.
What should the nurse do FIRST?
Report the assessment findings to the RN.
Elevate the head of bed and administer oxygen.
Administer an oral antitussive agent.
Increase the intravenous fluid flow rate.
The Correct Answer is B
Choice B rationale
The client's symptoms of sudden chest pain and hemoptysis (blood-tinged sputum) following a major orthopedic surgery are classic signs of a pulmonary embolism. The nurse's first priority is to stabilize the client's respiratory status. Elevating the head of the bed helps maximize lung expansion and ease dyspnea, while administering oxygen addresses potential hypoxia. These immediate nursing actions must be taken to ensure safety and oxygenation while preparing for further medical intervention and diagnostic testing.
Choice A rationale
While it is essential to report these critical findings to the Registered Nurse or healthcare provider, it is not the very first action. In an emergency situation where the client is symptomatic, the nurse must first implement immediate life-sustaining or comfort-measuring interventions. Once the head of the bed is elevated and oxygen is applied, the nurse should then immediately communicate the assessment data to the rest of the medical team to initiate the emergency protocol for a suspected embolism.
Choice C rationale
Administering an oral antitussive is inappropriate and potentially dangerous in this scenario. A cough producing blood-tinged sputum after surgery is a sign of a serious underlying vascular or respiratory complication, not a simple irritant cough that needs suppression. Using a medication to stop the cough would do nothing to address the physiological cause of the chest pain and could mask worsening symptoms, delaying the necessary diagnosis and treatment of a life-threatening pulmonary embolism.
Choice D rationale
Increasing the intravenous fluid flow rate without a specific order could be harmful. If the client's symptoms are due to a pulmonary embolism or potential heart failure, adding more fluid to the circulatory system could increase the workload on the right side of the heart and exacerbate pulmonary congestion. The priority is respiratory support and stabilization; fluid adjustments should only be made after a medical evaluation and specific orders are received based on the client's hemodynamic status. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Oxygen is a potent accelerant that supports combustion, making any open flame or spark extremely dangerous in its presence. Smoking while using oxygen, especially in a confined space like a bed, creates an immediate and severe fire hazard that can lead to catastrophic burns or death. This statement demonstrates a critical lack of understanding regarding basic safety protocols and indicates that the patient requires intensive additional education before discharge to ensure safety.
Choice B rationale
Posting signs indicating that oxygen is in use serves as a vital warning for visitors, emergency responders, and household members. These signs alert individuals to the presence of a concentrated oxidizer, reminding them to avoid bringing lighters, matches, or other ignition sources into the environment. This is a standard and correct safety practice for home oxygen therapy, reflecting that the patient understands the importance of maintaining a fire-safe environment in their residence.
Choice C rationale
Keeping oxygen tanks away from flames, heaters, and sparks is a fundamental safety requirement because the gas significantly increases the intensity of a fire. Oxygen cylinders are also under high pressure and can become projectiles or explode if exposed to extreme heat. Correctly identifying that tanks must be stored in a cool, well-ventilated area away from heat sources shows the patient has grasped the physical risks associated with the equipment and its storage requirements.
Choice D rationale
Using water-based lubricants, such as K-Y Jelly, around the nose is the correct method for relieving the dryness or irritation often caused by nasal cannulas. Petroleum-based products, like Vaseline, are highly flammable and should never be used near oxygen delivery systems as they can spontaneously ignite in an oxygen-rich environment. The patient's preference for water-based products indicates a correct understanding of how to manage comfort while strictly adhering to essential fire safety guidelines.
Correct Answer is C
Explanation
Choice A rationale
A flow rate of 5 liters per minute is generally too high for a patient with chronic obstructive pulmonary disease. High concentrations of oxygen can abolish the hypoxic drive in these patients. In chronic CO2 retainers, the central chemoreceptors become desensitized to high carbon dioxide levels, leaving low oxygen levels as the primary stimulus for breathing. Providing 5 liters could lead to hypoventilation, carbon dioxide narcosis, and potentially lethal respiratory arrest in susceptible individuals.
Choice B rationale
Delivering 8 liters per minute of oxygen is contraindicated for most individuals with chronic obstructive pulmonary disease unless they are in acute respiratory failure and being closely monitored with mechanical ventilation. This high flow rate significantly increases the partial pressure of arterial oxygen, which suppresses the peripheral chemoreceptors in the carotid and aortic bodies. The result is a dangerous decrease in minute ventilation and an exacerbation of hypercapnia and respiratory acidosis.
Choice C rationale
A flow rate of 2 liters per minute is the standard starting point for patients with chronic obstructive pulmonary disease to maintain an oxygen saturation between 88 percent and 92 percent. This level provides sufficient oxygenation to prevent tissue hypoxia while ensuring the arterial oxygen level does not rise high enough to suppress the patient's natural respiratory drive. Normal arterial oxygen (PaO2) for healthy adults is 80 to 100 mmHg, but COPD patients often compensate at lower levels.
Choice D rationale
A flow rate of 10 liters per minute is an excessive amount of supplemental oxygen for a stable COPD patient. Such high flows are typically reserved for emergency situations using non-rebreather masks. In the context of chronic management, this flow rate would almost certainly lead to a significant rise in PaCO2. Clinical guidelines emphasize using the lowest possible dose of oxygen to achieve adequate saturation to avoid the complications associated with oxygen-induced hypercapnia and loss of drive.
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