A client who has undergone surgery for Cushing's disease is in the postanesthesia care unit (PACU). The nurse notes that the client has a low blood pressure and a high heart rate.
What should the nurse prioritize in this situation?
Notify the healthcare provider about the client's cardiac status.
Increase the client's oxygen flow to enhance oxygenation.
Encourage the client to take deep breaths to improve respiratory function.
Administer IV fluids as ordered.
The Correct Answer is D
Choice A rationale
While notifying the healthcare provider is necessary, it is not the most immediate priority when the patient shows signs of hemodynamic instability. The nurse must first intervene to stabilize the patient's circulatory volume. Postoperative patients who have had surgery for Cushing's disease are at high risk for acute adrenal insufficiency. This occurs because the remaining adrenal tissue may be atrophied and unable to produce sufficient cortisol, leading to a life-threatening addisonian crisis.
Choice B rationale
Increasing oxygen flow may be supportive, but it does not address the underlying physiological cause of low blood pressure and tachycardia in this specific postoperative context. The primary issue is likely a lack of circulating cortisol and subsequent fluid volume deficit or vasodilation. While maintaining oxygen saturation is part of standard PACU care, it will not correct the hypotension or the potential adrenal crisis that is developing, making it a secondary intervention in this scenario.
Choice C rationale
Encouraging deep breaths is a standard intervention to prevent atelectasis and improve respiratory function after general anesthesia. However, it is not a priority when the patient is exhibiting signs of shock, such as hypotension and tachycardia. These vital sign changes suggest a cardiovascular or endocrine emergency rather than a primary respiratory problem. The nurse must focus on interventions that will restore blood pressure and ensure adequate organ perfusion to prevent further deterioration.
Choice D rationale
Administering IV fluids is the priority action to treat hypotension and tachycardia, which are signs of potential acute adrenal insufficiency or hypovolemia. In the absence of high cortisol levels after removing a tumor, the body cannot maintain vascular tone or fluid balance effectively. Rapid fluid resuscitation helps restore circulating volume and blood pressure. Following fluid initiation, the nurse should also prepare to administer parenteral hydrocortisone as ordered to replace the missing adrenal hormones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Radiation therapy for pancreatic cancer typically causes a decrease in appetite, known as anorexia, rather than an increase. The radiation affects the gastric and intestinal mucosa, leading to the release of cytokines that suppress the hunger center in the hypothalamus. Furthermore, the tumor itself and the localized inflammatory response in the abdomen often result in early satiety and nausea, making an increased appetite a highly unlikely finding during this treatment.
Choice B rationale
Weight gain is not expected during radiation for pancreatic cancer; instead, weight loss is a hallmark side effect. The combination of malabsorption due to pancreatic insufficiency and the systemic effects of radiation therapy leads to a catabolic state. Patients often struggle to maintain their caloric intake because of gastrointestinal distress and metabolic changes. Monitoring for weight loss is crucial, as significant drops can impair the patient's ability to tolerate the full course of treatment.
Choice C rationale
Koplik spots are small, white spots on the buccal mucosa that are pathognomonic for measles. They have no physiological connection to radiation therapy or pancreatic cancer. This finding would indicate a viral infection rather than a side effect of localized external beam radiation to the abdomen. The nurse focuses on skin integrity within the radiation field and systemic gastrointestinal symptoms rather than assessing for signs of unrelated infectious childhood diseases like rubeola.
Choice D rationale
External beam radiation to the pancreas involves the delivery of high-energy rays that inevitably pass through the small and large intestines. This causes radiation enteritis, where the rapidly dividing cells of the intestinal lining are damaged, leading to inflammation and impaired fluid absorption. Diarrhea is a frequent and expected adverse effect of this localized treatment. The nurse must monitor stool frequency and consistency while assessing for signs of dehydration and electrolyte imbalances.
Correct Answer is B
Explanation
Choice A rationale
This description incorrectly identifies the metastatic status of the malignancy. The M0 designation specifically indicates that there is no evidence of distant metastasis according to clinical and radiographic findings. Furthermore, T2 typically describes a tumor that is between 3 cm and 5 cm in its greatest dimension, which is considered moderate rather than strictly small. N1 represents limited involvement of ipsilateral peribronchial or hilar lymph nodes rather than significant or extensive regional nodal spread.
Choice B rationale
The TNM staging system provides a standardized method for describing the anatomical extent of lung cancer. A T2 classification denotes a primary tumor greater than 3 cm but less than or equal to 5 cm in size. The N1 status indicates that the malignancy has spread to the regional ipsilateral hilar or peribronchial lymph nodes. Finally, the M0 component confirms that no distant metastasis to other organs or contralateral lung tissues has been detected during staging.
Choice C rationale
This interpretation fails to align with the specific numerical values provided in the TNM classification. Large tumors with significant local spread into the mediastinum or heart would be classified as T4 rather than T2. Additionally, the presence of distant organ involvement would require an M1 designation, which contradicts the M0 status provided in the scenario. The scientific evidence indicates a localized and regional stage rather than an advanced systemic progression of the disease.
Choice D rationale
Extensive local node involvement would typically be classified as N2 or N3, which involves mediastinal or contralateral nodes, rather than the N1 stage mentioned. Very small tumors are often staged as T1 if they are 3 cm or less. Most importantly, the claim that the cancer has metastasized to distant organs is medically inaccurate because the M0 classification signifies a lack of distant spread. Therefore, this choice misrepresents every component of the staging data.
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