A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?

Measure the client's abdominal girth.

Monitor the client's recent hemoglobin levels.

Prepare for nasogastric tube (NGT) insertion.

Notify the healthcare provider (HCP) of the client's status.

Answer and Explanation

The Correct Answer is D

A. Measure the client's abdominal girth. While tracking abdominal distension is useful, it does not address the underlying cause of the client's deterioration. Measuring girth should not delay immediate intervention for a potentially life-threatening condition.
B. Monitor the client's recent hemoglobin levels. A drop in hemoglobin would indicate internal bleeding, but waiting for lab results could delay necessary treatment. The client is already showing signs of early shock, requiring urgent medical intervention rather than just monitoring.
C. Prepare for nasogastric tube (NGT) insertion. An NGT may be needed for bowel obstruction or paralytic ileus, but the client's worsening condition suggests a more urgent issue, such as intra-abdominal hemorrhage. Addressing the potential bleeding takes priority over decompression.
D. Notify the healthcare provider (HCP) of the client's status. The client's tachycardia, tachypnea, cool pale skin, and worsening abdominal distension suggest early shock, likely due to postoperative internal bleeding or abdominal compartment syndrome. Immediate notification of the HCP ensures rapid assessment, diagnostic testing, and potential emergency intervention to prevent further deterioration.

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Correct Answer is ["5"]

Explanation

Calculation:

Calculate the New Nitroglycerin Dose in mcg/hour

Dose (mcg/hour) = Dose (mcg/min) × 60 min/hour

=15 mcg/min × 60 min/hour = 900 mcg/hour

Convert mcg to mg

Dose (mg/hour) = Dose (mcg/hour) / 1000 mcg/mg

=900 mcg/hour / 1000 mcg/mg

= 0.9 mg/hour

Calculate the Concentration of Nitroglycerin in the IV Bag

Concentration (mg/mL) = Total mg of Nitroglycerin / Total mL of Solution

=50 mg / 250 mL

= 0.2 mg/mL

Calculate the Infusion Rate = Infusion Rate (mL/hour)

=0.9 mg/hour / 0.2 mg/mL

= 4.5 mL/hour

Round to the Nearest Whole Number

4.5 mL/hour rounded to 5 mL/hour

A. Notify healthcare provider (HCP) of the symptoms and administer a PRN pain medication. B. Increase the client's IV flow rate and start low flow oxygen. C. Position the client on the left side while immobilizing the affected leg. D. Take the client's vital signs and auscultate all lung sounds.

Correct Answer is B

Explanation

A. Notify healthcare provider (HCP) of the symptoms and administer a PRN pain medication. While notifying the HCP is necessary, administering pain medication does not address the underlying cause of the client’s acute chest pain and difficulty breathing. These symptoms suggest a possible pulmonary embolism (PE), a life-threatening complication after orthopedic surgery. Immediate supportive interventions should be initiated before notifying the provider.
B. Increase the client's IV flow rate and start low-flow oxygen. The client is experiencing acute respiratory distress, which could indicate a pulmonary embolism (PE), a fat embolism, or another postoperative complication. Providing oxygen helps improve oxygenation and reduce hypoxia, while increasing the IV flow rate helps maintain perfusion and prevent shock. These immediate interventions support vital functions while preparing for further medical management.
C. Position the client on the left side while immobilizing the affected leg. This position is used in air embolism management, not pulmonary embolism. In suspected PE, the priority is to optimize oxygenation and circulation rather than repositioning. The affected leg should be immobilized to prevent further embolization, but this is not the first priority.
D. Take the client's vital signs and auscultate all lung sounds. While assessing the client’s vital signs and lung sounds is important, intervention should not be delayed. The priority is to support oxygenation and circulation immediately, as PE can rapidly lead to hypoxia, hemodynamic instability, or cardiac arrest. Assessment should be done concurrently with emergency interventions.

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A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["5"]

Explanation

Twelve hours following orthopedic surgery on the right leg, the client begins to have acute chest pain and difficulty breathing. Which action should the nurse take first?

Correct Answer is B

Explanation

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