A nurse is caring for a 24-year-old female client who fell while horseback riding in the accident emergency unit.

Exhibits
A nurse is preparing the client for surgery. Based on the provided data, which of the following are the most critical to address before proceeding with the exploratory laparotomy? Select all that apply.

Hemoglobin of 9.3 g/dL

Prothrombin time of 11.5 seconds

Blood pressure of 90/48 mm Hg

Heart rate of 110 beats/minute

Abdominal distention

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale: Hemoglobin of 9.3 g/dL indicates that the client has anemia, likely due to blood loss from the injury. This low hemoglobin level suggests significant bleeding, which needs to be addressed to ensure adequate oxygen delivery to tissues during surgery.

Choice B rationale: Prothrombin time of 11.5 seconds is within the normal range and does not indicate a critical issue that needs to be addressed before surgery. It suggests that the client's blood clotting mechanism is functioning properly.

Choice C rationale: Blood pressure of 90/48 mm Hg indicates hypotension, which is a sign of shock or significant blood loss. It is critical to stabilize the client's blood pressure to ensure adequate perfusion to vital organs during surgery.

Choice D rationale: Heart rate of 110 beats/minute is elevated, which may be a response to pain, anxiety, or hypovolemia. While it is important to monitor, it is not as critical as addressing the hypotension and anemia before surgery.

Choice E rationale: Abdominal distention indicates potential internal bleeding or injury to abdominal organs. This needs to be addressed urgently, as it can lead to further complications and affect the outcome of the surgery.

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Correct Answer is A

Explanation

Choice A rationale

Reporting the client's jaw pain to the healthcare provider is crucial because jaw pain is a potential symptom of osteonecrosis of the jaw (ONJ), a rare but serious side effect of bisphosphonates like alendronate. ONJ involves the death of bone tissue in the jaw, leading to significant complications. Early intervention and management are essential to prevent further deterioration and address any underlying issues.

Choice B rationale

Determining how the client is administering the medication is important but not the immediate priority when addressing jaw pain, which could indicate a serious complication. Ensuring proper administration can prevent future issues but does not address the immediate concern of potential ONJ.

Choice C rationale

Advising the client to gargle with warm salt water twice daily may provide temporary relief from minor oral discomfort but is not appropriate for addressing potential osteonecrosis of the jaw. This suggestion does not address the underlying cause of jaw pain in a client taking bisphosphonates.

Choice D rationale

Confirming that jaw pain is a common symptom of osteoporosis is incorrect. While musculoskeletal pain can be associated with osteoporosis, jaw pain in a client taking alendronate may indicate osteonecrosis of the jaw, a serious condition requiring prompt medical attention.

A. Check for pedal edema. B. Measure body temperature. C. Observe the color of urine. D. Assess skin turgor.

Correct Answer is C

Explanation

Choice A rationale

Pedal edema is an assessment related to heart failure or peripheral vascular disease but is not specifically connected to the adverse effects of prasugrel, which is an antiplatelet medication that primarily affects blood clotting processes.

Choice B rationale

Measuring body temperature can help detect infections or fever, but it is not a primary assessment for the adverse effects of prasugrel. The medication's adverse effects are more closely related to bleeding risks.

Choice C rationale

Prasugrel, an antiplatelet medication, increases the risk of bleeding. Observing the color of urine can help detect hematuria, an indication of internal bleeding, making it a critical assessment for clients taking this medication.

Choice D rationale

Assessing skin turgor is generally used to evaluate hydration status, not to monitor for adverse effects of prasugrel. This assessment would not provide relevant information about bleeding risks associated with prasugrel use.

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Naxlex Comprehensive Predictor Exams

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is A

Explanation

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

Correct Answer is C

Explanation

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