A nurse is caring for a one-day postoperative client. Which of the following would be the priority for the nurse?
Client blood pressure 118/70
Client reports pain severity 6/10
Client appears anxious when family arrives
Client requests information about pain medications
The Correct Answer is B
Choice A reason: Blood pressure 118/70 is normal, indicating stable hemodynamics. Pain (6/10) is more urgent, as uncontrolled pain increases stress hormones, impairing healing and risking complications like atelectasis, making blood pressure a lower priority in this postoperative scenario.
Choice B reason: Pain severity of 6/10 is a priority, as moderate postoperative pain increases catecholamine release, impairing healing and raising risks of complications like atelectasis or hypertension. Prompt pain management improves recovery, preventing physiological stress, making this the most urgent issue to address.
Choice C reason: Anxiety when family arrives is psychosocial but less urgent than pain (6/10). Pain causes physiological stress, increasing risks like impaired healing or respiratory complications, while anxiety’s impact is less immediate, making it secondary to effective pain management.
Choice D reason: Requesting pain medication information indicates a need for education but is less urgent than addressing pain (6/10). Uncontrolled pain risks physiological complications like increased heart rate or poor healing, making pain management the priority over providing medication information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Rolled gauze and sterile saline are used for general wound care but are inadequate for chest tube emergencies. If a tube dislodges, an occlusive dressing prevents air entry into the pleural space, avoiding pneumothorax, making this choice insufficient for emergency preparedness in chest tube management.
Choice B reason: A petrolatum-impregnated sterile occlusive dressing is critical for chest tube emergencies. If the tube dislodges, it seals the pleural space, preventing air entry and reducing pneumothorax risk. This ensures immediate response to maintain lung function, making it the priority supply for emergency preparedness.
Choice C reason: Suction tubing and Yankauer suction tip clear oral or airway secretions, not chest tube issues. They are irrelevant for emergencies like tube dislodgement, where sealing the pleural space prevents pneumothorax, making this choice inappropriate for chest tube emergency preparedness in this scenario.
Choice D reason: Non-adhesive dressings and tracheostomy tubes are for tracheostomy care, not chest tubes. They do not address emergencies like tube dislodgement, which require an occlusive dressing to prevent air entry, rendering this choice incorrect for chest tube emergency preparedness in this context.
Correct Answer is B
Explanation
Choice A reason: Oxygen and suction equipment support respiratory function but are not the priority for opioid-induced respiratory depression from morphine. Lethargy and low respiratory rate (8 breaths/min) indicate overdose, requiring naloxone to reverse opioid effects first, as hypoxia can persist without addressing the primary cause.
Choice B reason: Naloxone, an opioid antagonist, reverses morphine-induced respiratory depression and lethargy. A respiratory rate of 8 breaths/min signals overdose, risking hypoxia and brain damage. Naloxone restores normal respiration by blocking opioid receptors, making it critical to have readily available for immediate administration in this scenario.
Choice C reason: IV fluids may support blood pressure but are not the priority for opioid-induced respiratory depression. Lethargy and low respiratory rate indicate morphine toxicity, requiring naloxone to reverse effects. Fluids address secondary issues like hypovolemia, not the primary concern of respiratory compromise in this case.
Choice D reason: A blood pressure monitor is unnecessary, as the client’s blood pressure (118/66) is stable. The critical issue is respiratory depression and lethargy from morphine, requiring naloxone. Monitoring blood pressure is secondary to addressing life-threatening respiratory compromise caused by opioid overdose in this postoperative client.
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