A nurse is caring for a client after surgery whose respiratory rate has increased from 12 to 18 breaths/minute and the pulse rate increased from 86 to 98 beats/minute in the last four hours. What action by the nurse is best?

Administer the prescribed pain medication

Document the findings in the client’s chart

Assess the client using the modified early warning score (MEWS)

Increase the rate of the client’s intravenous (IV) infusion

Answer and Explanation

The Correct Answer is C

Choice A reason: Administering pain medication might be appropriate if the patient reports pain, but the nurse must first determine the cause of the physiological changes. Pain is only one possible reason for tachycardia and tachypnea; other causes include hemorrhage, sepsis, or pulmonary embolism that require different treatments.

Choice B reason: Simply documenting the findings is insufficient. The patient is showing a trend of physiological instability with increasing heart and respiratory rates. Nursing responsibility includes analyzing these trends and performing a more comprehensive assessment to catch potential complications before they escalate into a crisis.

Choice C reason: The Modified Early Warning Score (MEWS) is a validated clinical tool used to identify patients at risk for clinical deterioration. By calculating a score based on vital signs and consciousness, the nurse can objectively determine if a higher level of care or physician notification is required for this patient.

Choice D reason: Increasing the IV infusion rate without a specific order or a clear diagnosis of hypovolemia is outside the nurse’s scope of practice. It could also be harmful if the patient’s symptoms are related to cardiac strain or fluid overload rather than a deficit in intravascular volume.

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Correct Answer is A

Explanation

Choice A reason: Burn dressing changes are notoriously painful due to the exposure of raw tissue and mechanical debridement. Pre-medicating the client 20 to 30 minutes prior to the procedure ensures therapeutic drug levels are reached, facilitating client cooperation and preventing the physiological stress response associated with severe pain.

Choice B reason: Removing the old dressing is a necessary step, but it must occur after pain management has been addressed. If the nurse removes the dressing without prior medication, the client may experience excruciating pain, making it difficult to complete the sterile portion of the procedure safely.

Choice C reason: Preparing equipment at the bedside is a logistical requirement for any procedure. While important for efficiency, it does not take priority over the ethical and clinical necessity of ensuring the client is comfortable and physiologically prepared for a painful intervention.

Choice D reason: Placing a sterile glove is one of the final steps in the actual dressing application process. It occurs long after the initial assessment, pain management, and removal of the old dressing. Proper sequencing ensures that the sterile field remains uncontaminated throughout the procedure.

A. Check the client’s hemoglobin & hematocrit level B. Obtain a STAT electrocardiogram (EKG) C. Monitor the client’s temperature D. Check the client’s platelets, PT, and INR

Correct Answer is D

Explanation

Choice A reason: Hemoglobin and hematocrit levels are indicators of the total red blood cell mass and oxygen carrying capacity. While these values are important to assess the severity of blood loss already sustained, they do not help identify the underlying coagulopathy causing the spontaneous bleeding from multiple unrelated sites.

Choice B reason: A STAT electrocardiogram is used to assess cardiac rhythm and identify myocardial ischemia or conduction abnormalities. While septic shock can place significant strain on the cardiovascular system, an EKG is not the priority diagnostic tool for a patient exhibiting signs of systemic, multi-site spontaneous hemorrhage.

Choice C reason: Monitoring the client’s temperature is a standard part of assessing a patient with sepsis to track the inflammatory response or the effectiveness of antibiotic therapy. However, thermoregulation assessment does not address the immediate life threatening risk associated with suspected disseminated intravascular coagulation and active bleeding.

Choice D reason: The clinical presentation of oozing from IV sites, bleeding gums, and hematuria in a septic patient is highly suggestive of disseminated intravascular coagulation. Checking the platelet count, Prothrombin Time, and International Normalized Ratio is the critical first step to confirm a consumption coagulopathy and guide blood product replacement.

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A nurse is caring for a client after surgery whose respiratory rate has increased from 12 to 18 breaths/minute and the pulse rate increased from 86 to 98 beats/minute in the last four hours. What action by the nurse is best?

Nursing Test Bank

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Correct Answer is A

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Correct Answer is D

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