A nurse is caring for a patient in the post-anesthesia care unit (PACU) who underwent a procedure two hours ago.

The nurse observes the following vital signs: heart rate 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute.

Which intervention is most important for the nurse to implement?

Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.

Medicate for pain and monitor vital signs according to protocol.

Encourage the client to splint the incision with a pillow to cough and deep breathe.

Administer intravenous fluid bolus as prescribed by the healthcare provider.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Applying oxygen at 10 L via non-rebreather mask and monitoring pulse oximeter is the most important intervention for a patient in the post-anesthesia care unit (PACU) with a heart rate of 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute.
These vital signs suggest that the patient may be experiencing hypoxia or respiratory distress, conditions that require immediate intervention.
Choice B rationale
Medicating for pain and monitoring vital signs according to protocol is important in the PACU, but it is not the most critical intervention in this scenario. The patient’s vital signs suggest a possible respiratory issue, which should be addressed immediately.
Choice C rationale
Encouraging the client to splint the incision with a pillow to cough and deep breathe is a common postoperative intervention to promote lung expansion and prevent atelectasis and pneumonia. However, in this scenario, the patient’s vital signs suggest a more immediate respiratory issue that requires prompt intervention.
Choice D rationale
Administering an intravenous fluid bolus as prescribed by the healthcare provider can be an appropriate intervention for certain conditions in the PACU, such as hypotension. However, in this scenario, the patient’s vital signs suggest a possible respiratory issue, which should be addressed immediately.

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Correct Answer is C

Explanation

Choice A rationale
A CT scan of the chest can be performed to detect the severity of infection in pneumonia. However, it is not typically the first diagnostic test prescribed. It is usually recommended if the pneumonia isn’t clearing as quickly as expected.
Choice B rationale
Arterial blood gases (ABG) can be used to measure the oxygen level in your blood. Pneumonia can prevent your lungs from moving enough oxygen into your bloodstream. However, ABG is not typically the first diagnostic test prescribed for pneumonia.
Choice C rationale
A sputum culture test is often used to confirm the cause of infection in pneumonia. This test involves taking a sample of fluid from your lungs (sputum) after a deep cough and analyzing it to help pinpoint the cause of the infection.
Choice D rationale
Blood cultures can identify the germ causing your pneumonia and also show whether a bacterial infection has spread to your blood. However, they are not typically the first diagnostic test prescribed for pneumonia.

A. Guidelines for oxygen use. B. Approaches to conserve energy. C. Strategies for smoking cessation. D. Methods for weight loss.

Correct Answer is A

Explanation

Choice A rationale
For a client with emphysema who will be discharged with oxygen, understanding the guidelines for oxygen use is crucial. Misuse of oxygen can lead to serious health complications, so it’s important that the client knows how to use it correctly.
Choice B rationale
While energy conservation approaches can be beneficial for a client with emphysema, they are not as crucial as understanding the guidelines for oxygen use.
Choice C rationale
While smoking cessation strategies are important for a client with emphysema, especially one who smokes heavily, they are not as crucial as understanding the guidelines for oxygen use.
Choice D rationale
While weight loss methods can be beneficial for an obese client, they are not as crucial as understanding the guidelines for oxygen use for a client with emphysema who will be discharged with oxygen.

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes diagnostic tests for a patient whose chest x-ray indicates pneumonia. Which diagnostic test should the nurse prepare the patient for?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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