A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?
Apply wrist restraints to secure IV lines.
Administer the prescribed opioid.
Take the blood pressure and pulse.
Check the oxygen (O2) saturation.
The Correct Answer is D
Choice A: Apply wrist restraints to secure IV lines
Applying wrist restraints to secure IV lines should not be the first action. Restraints are generally considered a last resort due to their potential to cause harm and distress. They should only be used when absolutely necessary and after other interventions have failed. In this scenario, the patient’s agitation and confusion could be due to hypoxia, and addressing the underlying cause is more important than immediately resorting to restraints.
Choice B: Administer the prescribed opioid
Administering the prescribed opioid is not the first action to take. While pain management is crucial, opioids can sometimes exacerbate confusion and agitation, especially in the immediate postoperative period. It is essential to first assess the patient’s vital signs and oxygen levels to rule out hypoxia or other complications before administering any medication.
Choice C: Take the blood pressure and pulse
Taking the blood pressure and pulse is important but not the immediate first action. While these vital signs provide critical information about the patient’s cardiovascular status, checking the oxygen saturation is more urgent in this context. Hypoxia can lead to agitation and confusion, and addressing it promptly can stabilize the patient more effectively.
Choice D: Check the oxygen (O2) saturation
Checking the oxygen (O2) saturation should be the first action. Hypoxia is a common cause of postoperative agitation and confusion. By assessing the patient’s oxygen levels, the nurse can quickly determine if supplemental oxygen is needed, which can help alleviate the patient’s symptoms and prevent further complications. Ensuring adequate oxygenation is a priority in the immediate postoperative period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: True
Chemotherapy drugs work by targeting rapidly dividing cells, a characteristic of cancer cells. However, they cannot selectively distinguish between cancer cells and normal cells that also divide rapidly, such as those in the bone marrow, digestive tract, and hair follicles. This lack of selectivity leads to the common side effects of chemotherapy, such as hair loss, nausea, and decreased blood cell counts. The inability to differentiate between normal and cancer cells is a significant limitation of traditional chemotherapy.
Choice B: False
This choice is incorrect. If chemotherapy drugs could selectively target only cancer cells, the treatment would have fewer side effects and be more effective. However, the non-selective nature of these drugs means they also damage normal, healthy cells that divide rapidly. This non-selectivity is why patients undergoing chemotherapy often experience a range of side effects, as the treatment impacts both cancerous and healthy cells.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A: Collect patient information
This is the first step in the nursing process, known as the assessment phase. During this phase, the nurse gathers comprehensive information about the patient’s health status, including medical history, physical examination findings, and any relevant diagnostic test results. This information forms the foundation for identifying the patient’s health needs and planning appropriate care.
Choice B: Identify any clinical problems
The second step is the diagnosis phase, where the nurse analyzes the collected data to identify the patient’s health problems. These problems can be actual or potential issues that require nursing intervention. Accurate identification of clinical problems is crucial for developing an effective care plan.
Choice C: Decide a plan of action
The third step is the planning phase. In this phase, the nurse sets measurable and achievable goals for the patient’s care and decides on the appropriate nursing interventions to address the identified clinical problems. The plan of action should be individualized to meet the specific needs of the patient.
Choice D: Carry out the plan
The fourth step is the implementation phase, where the nurse executes the planned interventions. This may involve administering medications, providing education, performing procedures, or coordinating with other healthcare professionals. The goal is to achieve the desired patient outcomes as outlined in the care plan.
Choice E: Determine whether the plan was effective
The final step is the evaluation phase. In this phase, the nurse assesses the patient’s response to the implemented interventions and determines whether the goals of the care plan have been met. If the desired outcomes are not achieved, the nurse may need to revise the care plan and repeat the process.
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