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 A

Explanation

Lower back pain and hypotension are symptoms of an ABO incompatibility reaction, which is a serious complication of blood transfusion. This reaction occurs when the client receives a blood type that is incompatible with their own. It can cause a rapid and severe response, including back pain, hypotension, fever, and chills. This should be reported immediately to the healthcare provider.

A. Use an incentive spirometer. B. Monitor the urinary stream for decreased output. C. Restrict physical activities. D. Report when hematuria becomes pink-tinged.

Correct Answer is B

Explanation

Choice A rationale
Using an incentive spirometer is generally recommended for respiratory conditions to improve lung function, not specifically for a client with hydronephrosis and a history of renal calculi.
Choice B rationale
Monitoring the urinary stream for decreased output is crucial for a client with hydronephrosis and a history of renal calculi. Hydronephrosis is a condition characterized by urine accumulation in the kidney, which can lead to decreased urine output. Therefore, monitoring urinary output can help detect any potential complications or worsening of the condition.
Choice C rationale
Restricting physical activities is not typically necessary for a client with hydronephrosis and a history of renal calculi unless specified by the healthcare provider. It’s more important to focus on maintaining overall health and well-being.
Choice D rationale
Reporting when hematuria becomes pink-tinged is not the most relevant instruction for a client with hydronephrosis and a history of renal calculi. While it’s important to report any changes in urine color, monitoring urinary output (Choice B) is more directly related to the client’s condition.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

A client with right hydronephrosis and a history of renal calculi is preparing for discharge following a retrograde pyelogram. Which instruction should the nurse include in the client’s discharge instructions?

Correct Answer is B

Explanation

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

A nurse is caring for a patient who has been admitted to the hospital with a suspected diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the patient for?

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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?

The nurse is caring for a patient with chronic pancreatitis who reports persistent gnawing abdominal pain. What assessment data is most important for the nurse to obtain to help manage the patient’s pain?

An hour after administering 60 mg of furosemide intravenously (IV), which assessments should the nurse perform to determine the patient’s response to treatment? (Select all that apply.)