A nurse is preparing a client for a hip arthroplasty. For which of the following reasons should the nurse assess the client's vital signs?
To determine how the client will tolerate the procedure
To establish a baseline for postoperative assessment
To prevent postoperative hypotension
To assess the client's pain level
The Correct Answer is B
A. Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, provide baseline information about the client's cardiovascular and respiratory status. This assessment helps predict how well the client might tolerate the surgical procedure under anesthesia and monitor for any deviations during the procedure.
B. Establishing baseline vital signs before surgery provides a comparison point for monitoring the client's recovery and identifying any postoperative complications. Changes in vital signs postoperatively can indicate potential issues such as bleeding, fluid imbalance, or respiratory compromise.
C. Monitoring blood pressure before surgery helps identify clients at risk for intraoperative hypotension, particularly important during induction of anesthesia and throughout the surgical procedure. Establishing baseline blood pressure levels guides intraoperative management to maintain hemodynamic stability.
D. While vital signs are important for assessing physiological status, they do not directly assess pain. Pain assessment involves asking the client about their pain experience, location, intensity, and factors that alleviate or exacerbate pain. Vital signs can indirectly reflect pain if pain causes changes in heart rate or blood pressure, but they are not specific indicators of pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This condition occurs because the suctioning can lead to a significant loss of hydrochloric acid from the stomach. Since hydrochloric acid is one of the components that maintain the acid-base balance in the body, its loss can lead to an increase in blood pH, causing alkalosis
B. Respiratory acidosis occurs due to retention of carbon dioxide (CO2), leading to an increase in PaCO2 and a decrease in pH. In the context of a small bowel obstruction with nasogastric tube suctioning, this is less likely unless there are concurrent respiratory issues.
C. This condition occurs because the suctioning can lead to a significant loss of hydrochloric acid from the stomach. Since hydrochloric acid is one of the components that maintain the acid-base balance in the body, its loss can lead to an increase in blood pH, causing alkalosis. Acidosis is, therefore, unlikely.
D. Respiratory alkalosis occurs due to hyperventilation, leading to a decrease in PaCO2 and an increase in pH. This is less likely in the context of nasogastric tube suctioning unless there are other contributing factors.
Correct Answer is D
Explanation
A. PaCO2 (partial pressure of carbon dioxide) reflects the respiratory component of acid-base balance. In metabolic acidosis, the respiratory system compensates by increasing ventilation to decrease PaCO2 (hyperventilation). Therefore, PaCO2 is typically below normal (less than 35-45 mm Hg) in metabolic acidosis, not above 45 mm Hg.
B. HCO3 (bicarbonate) is a buffer that helps regulate pH in the body. In metabolic acidosis, there is a primary decrease in HCO3 due to either increased acid production (e.g., lactic acidosis, ketoacidosis) or decreased acid elimination (e.g., renal failure). Therefore, HCO3 is typically below normal (< 22-26 mEq/L) in metabolic acidosis, not above 26 mEq/L.
C. PaO2 (partial pressure of oxygen) measures the oxygen level in the blood. It is not directly related to the diagnosis of metabolic acidosis. Low PaO2 levels may indicate respiratory dysfunction or impaired gas exchange but are not specific to metabolic acidosis.
D. pH below 7.35 indicates acidosis. In metabolic acidosis, the primary defect is a decrease in blood pH due to an excess of acids or a loss of bases. The pH typically decreases below the normal range of 7.35-7.45 in metabolic acidosis.
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