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 B

Explanation

Choice A rationale
Similar to, while spicy foods can irritate the urinary tract, they do not have a direct impact on the care and management of an indwelling urinary catheter after a TURP3.
Choice B rationale
As in, drinking 3 liters of water each day is important as it helps flush the bladder and reduce the risk of urinary tract infections, which are a common complication after a TURP3.
Choice C rationale
As in, clamping the catheter is not typically recommended as it can lead to urinary retention and increase the risk of urinary tract infections.
Choice D rationale
As in, avoiding driving for 2 weeks is a general recommendation after any major surgery to allow the body time to heal, but it does not directly relate to the care of an indwelling urinary catheter.

A. Lean beef, salads, and baked potatoes. B. Potatoes, low-fat breads, and applesauce. C. Oatmeal, raisins, and fruit with skin. D. Chicken, rice, and wheat products.

Correct Answer is C

Explanation

Choice A rationale
While lean beef, salads, and baked potatoes can be part of a balanced diet, they are not specifically recommended for patients with a strong family history of colon and rectal cancers.
Choice B rationale
Potatoes and low-fat breads can be part of a balanced diet, but they are not specifically recommended for patients with a strong family history of colon and rectal cancers.
Choice C rationale
Oatmeal, raisins, and fruit with skin are high in fiber, which promotes gut health and is beneficial for colorectal cancer prevention. A nutritious regular diet can improve your gut health, which is a main contributor to colon and rectal health.
Choice D rationale
Chicken, rice, and wheat products can be part of a balanced diet, but they are not specifically recommended for patients with a strong family history of colon and rectal cancers.

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Naxlex Comprehensive Predictor Exams

After a transurethral resection of the prostate (TURP), a patient is discharged from the hospital with an indwelling urinary catheter. What is the most important instruction for the nurse to include in the discharge teaching plan?

Correct Answer is B

Explanation

Which group of foods should the nurse recommend for patients with a strong family history of colon and rectal cancers?

Correct Answer is C

Explanation

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

The nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about huff coughing to clear secretions. During the patient’s return demonstration, the patient exhales using pursed lips. What should the nurse do next?

A nurse is educating a patient with Type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?

An elderly patient is admitted with an acute onset of diverticulitis, and intravenous antibiotic therapy is started. What should the nurse do next?

A client who was recently diagnosed with Raynaud’s disease is concerned about pain management. Which nursing instruction should the nurse provide?

Following a transurethral resection of the prostate (TURP), a patient is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan?