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 D

Explanation

Choice A rationale
Antibiotics are typically used to treat bacterial infections, not fungal infections like athlete’s foot. Therefore, using antibiotics would not be effective in this case.
Choice B rationale
While it’s important to use treatments for the full recommended duration to ensure the infection is completely eradicated, using an antibiotic ointment for a fungal infection like athlete’s foot would not be effective.
Choice C rationale
While it’s true that applying too much ointment can deter its effectiveness, the main issue here is that an antibiotic ointment is not the correct treatment for a fungal infection like athlete’s foot.
Choice D rationale
Athlete’s foot is a fungal infection that thrives in warm, moist environments. Therefore, keeping the feet dry and clean is an important part of managing and preventing athlete’s foot. This includes wearing clean socks and allowing the feet to dry completely before putting on shoes.

A. Notify the healthcare provider of the client’s medication history. B. Ensure that the potential for bleeding is explained to the client. C. Have the client sign the surgical and transfusion permits. D. Observe the heparin injection sites for signs of bruising.

Correct Answer is A

Explanation

Notifying the healthcare provider of the client’s medication history is the priority nursing action. Heparin is an anticoagulant, which increases the risk of bleeding. The healthcare provider needs this information to make appropriate decisions about the client’s surgical plan and postoperative care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parent of an adolescent tells the clinic nurse, “My child has athlete’s foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement.”. Which instruction should the nurse provide?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

While assessing a patient with degenerative joint disease, the nurse notices Heberden’s nodes, and large prominences on the patient’s fingers that are reddened and painful. What should the nurse do?

A patient with small cell carcinoma of the lung is admitted with syndrome of inappropriate antidiuretic hormone (SIADH). The patient’s serum sodium level increases from 120 mEq/L to 125 mEq/L as they respond to treatment. Based on this finding, what intervention should the nurse implement?

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage at the wound site. Before reporting this finding to the healthcare provider, which of the patient’s laboratory values should the nurse review?