A client presents to the emergency department complaining of headaches and blurred vision. The client's vital signs are as follows, Pulse 102 beats/minute, BP 172/92. RR 20 breaths/minute, SpO2.97% on room air temperature of 98.64. Which of the following interventions would be most appropriate for this patient?

Administer IV hydralazine and monitor blood pressure

Administer oxygen at 10 liters/minute by non rebreather mask

Administer acetaminophen 650 mg PO re-check temperature

Infuse 0.9% sodium chioride at 120 mL/hour

Answer and Explanation

The Correct Answer is A

A) "Administer IV hydralazine and monitor blood pressure":
. The patient's elevated blood pressure (172/92 mmHg), along with headaches and blurred vision, could indicate a hypertensive emergency, a serious condition where extremely high blood pressure can cause acute organ damage. Hydralazine is a common intravenous antihypertensive medication used to lower blood pressure quickly in these situations. The nurse should administer hydralazine as prescribed and closely monitor the blood pressure to prevent complications like stroke, heart failure, or kidney damage. Blood pressure management is the priority, as the patient's symptoms are likely related to the elevated BP.

B) "Administer oxygen at 10 liters/minute by non-rebreather mask":
. While oxygen therapy may be appropriate for patients with respiratory distress or hypoxia, the patient's SpO2 is 97% on room air, indicating that there is no immediate oxygenation issue. Administering oxygen unnecessarily could lead to oxygen toxicity, and it is not the priority in this case. The patient's main concern is their elevated blood pressure, which requires urgent management.

C) "Administer acetaminophen 650 mg PO re-check temperature":
. While headaches are one of the patient's complaints, there is no indication of fever (the temperature is 98.6°F). Administering acetaminophen would be appropriate for pain relief, but it is not the priority in this case. The elevated blood pressure and potential hypertensive emergency are the primary issues that need to be addressed first.

D) "Infuse 0.9% sodium chloride at 120 mL/hour":
. Normal saline (0.9% sodium chloride) is typically used for hydration, but there is no indication that the patient is dehydrated or that intravenous fluids are the priority. In cases of hypertensive emergency, the goal is to lower blood pressure using antihypertensive medications, not to infuse fluids. Fluid administration could potentially worsen the situation if the elevated blood pressure is not addressed first.

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Correct Answer is C

Explanation

A. Intramuscular epinephrine:
Intramuscular epinephrine is typically used in cases of anaphylactic reactions, which present with symptoms such as difficulty breathing, swelling, hives, and hypotension. Flank and lower back pain are not typical signs of an anaphylactic reaction during a blood transfusion. Instead, flank pain may suggest a hemolytic reaction, which involves the destruction of red blood cells, not an allergic or anaphylactic response. Thus, epinephrine would not be the first-line treatment for this situation.

B. Intravenous corticosteroids:
Intravenous corticosteroids are often used for inflammatory reactions, such as in cases of autoimmune diseases or severe allergic reactions. While corticosteroids might be used for certain types of transfusion reactions, they are not the primary treatment for hemolytic reactions (which could cause flank and lower back pain). The primary goal in a transfusion reaction with flank pain is to manage potential hemolysis and prevent kidney damage, which would be addressed through hydration and other supportive measures.

C. High volume IV fluids:
High-volume IV fluids are the most appropriate immediate intervention for a client who is experiencing flank and lower back pain during a blood transfusion, which are signs of a potential hemolytic reaction. Hemolysis, or the breakdown of red blood cells, can lead to kidney injury, so increasing fluid volume helps flush the kidneys, promote diuresis, and reduce the risk of kidney damage. The fluids also help to dilute any hemoglobin that is released into the bloodstream, supporting the kidneys' ability to filter it out. This is the priority intervention in this scenario.

D. PO diphenhydramine:
Oral diphenhydramine is used for allergic reactions, such as mild reactions involving itching, rashes, or hives, but it is not appropriate for managing more severe transfusion reactions, such as hemolytic reactions, that cause flank and lower back pain. Diphenhydramine would not address the underlying issue of potential hemolysis and kidney injury. Therefore, it is not the correct intervention for this situation.

A. Early ambulation can help keep your lungs expanded and prevent pneumonia B. Early ambulation is one part of preventing blood clots from forming in your legs C. Early ambulation usually delays wound healing and increases the risk wound infection D. Early ambulation can help your bladder and bowels recover from the anaesthesia

Correct Answer is C

Explanation

A. "Early ambulation can help keep your lungs expanded and prevent pneumonia":
This statement is correct. Early ambulation is beneficial for respiratory function as it helps to keep the lungs expanded, encouraging deeper breaths and better oxygenation. This can help prevent complications like pneumonia and atelectasis, which are common after surgery due to immobility and anesthesia.

B. "Early ambulation is one part of preventing blood clots from forming in your legs":
This statement is also correct. Early ambulation is an important measure in preventing deep vein thrombosis (DVT) and pulmonary embolism (PE), which are common postoperative complications. Movement and walking promote circulation, reducing the risk of blood clots forming in the legs.

C. "Early ambulation usually delays wound healing and increases the risk of wound infection":
This statement is incorrect. Early ambulation does not delay wound healing or increase the risk of infection. In fact, early movement can help improve circulation, which is crucial for wound healing and tissue repair. Gentle movement and ambulation typically have positive effects on wound healing by promoting blood flow to the surgical site. However, patients should avoid excessive strain or stress on the wound to prevent dehiscence or other complications.

D. "Early ambulation can help your bladder and bowels recover from the anesthesia":
This statement is correct. Early ambulation helps stimulate gastrointestinal and urinary systems, which may be sluggish after anesthesia. Walking can encourage the return of normal bowel and bladder function by promoting peristalsis and helping to prevent constipation or urinary retention, both of which can be common after surgery.

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Naxlex Comprehensive Predictor Exams

A client is receiving a blood transfusion, The nurse observes that the client is experiencing flank and lower back pain. Which of the following orders does the nurse anticipate receiving?

Correct Answer is C

Explanation

A nurse is discussing the benefits of early ambulation after surgery with a preoperative client. Which of the following statements would be incorrect?

Correct Answer is C

Explanation

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