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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Free Nursing Study Resources

Correct Answer is ["42"]

Explanation

Step 1: Convert the volume from liters to milliliters. 1 liter = 1000 mL. Step 2: Convert the time from hours to minutes. 4 hours = 240 minutes.

Step 3: Calculate the rate in mL per minute. Rate = Volume ÷ Time = 1000 mL ÷ 240 min = 4.17 mL/min.

Step 4: Calculate the drops per minute. Drops per minute = Rate × Drop factor = 4.17 mL/min

× 10 gtt/mL = 41.7 gtt/min.

Step 5: Round off the result to the nearest whole number. 41.7 gtt/min rounds off to 42 gtt/min.

A. Maintain elevated positioning of the dependent joints on the affected side. B. Verify prescribed laboratory tests include prothrombin time and platelet count. C. Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. D. Administer aspirin to prevent further clot formation and platelet clumping.

Correct Answer is C

Explanation

Choice A rationale
While maintaining elevated positioning of the dependent joints on the affected side can be helpful in certain conditions such as edema or injury, it is not the immediate intervention needed for a client presenting with sudden, severe facial numbness, uneven smile with facial droop to the right side, and a hand grasp strength that is weaker on the right than the left.
Choice B rationale
Verifying prescribed laboratory tests including prothrombin time and platelet count is important in assessing the client’s coagulation status. However, it is not the immediate intervention needed in this situation.
Choice C rationale
The client’s symptoms are suggestive of a stroke. In such cases, immediate medical intervention is crucial. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an appropriate immediate intervention.
Choice D rationale
Administering aspirin can be beneficial in preventing further clot formation and platelet clumping in clients at risk of a stroke. However, it is not the immediate intervention needed in this situation.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["42"]

Explanation

Correct Answer is C

Explanation

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