The client is a 43-year-old male who had a surgical removal of a benign tumor from the left hemisphere of his brain. The client's estimated blood loss (EBL) is 100 mL during surgical procedure. There were no complications. Vital signs remained stable throughout the procedure. The client will be admitted to the neurological intensive care unit for monitoring.

Answer and Explanation

The Correct Answer is []

Place the call light within the client's reach. The client has undergone surgery on the left hemisphere of the brain, which controls speech and motor function on the right side. This may lead to temporary weakness or speech difficulties, making it essential to ensure easy access to the call light for assistance.
Use a word board to help the client communicate. Damage to the left hemisphere can result in Broca aphasia, where the client has difficulty producing speech but can still understand language. A word board or communication aid allows the client to express needs effectively despite speech limitations.
Cerebral perfusion pressure. Monitoring cerebral perfusion pressure (CPP) is essential after brain surgery to ensure the brain is receiving adequate blood flow. Low CPP can lead to ischemia, while high CPP may indicate increased intracranial pressure (ICP), both of which can result in serious complications.
Level of consciousness. Assessing neurological status frequently helps detect early signs of deterioration, such as worsening intracranial pressure, cerebral edema, or postoperative bleeding. Changes in alertness, responsiveness, or confusion may indicate a need for urgent intervention.
Broca aphasia. Since the left hemisphere controls speech production, surgery in this area may cause Broca aphasia, where the client understands language but struggles to form words or complete sentences. The use of alternative communication methods is necessary to assist the client in expressing their needs.
Prepare the client to return to surgery. There is no indication of complications requiring an immediate return to the operating room. The estimated blood loss (100 mL) is minimal, and vital signs remained stable throughout the procedure.
Give ibuprofen as ordered. Ibuprofen (a nonsteroidal anti-inflammatory drug - NSAID) is contraindicated postoperatively because it can increase the risk of bleeding by inhibiting platelet function. Acetaminophen is typically preferred for pain control.
Elevate the head of the bed to 45 degrees. After brain surgery, the head of the bed should be elevated to 30 degrees, not 45 degrees. This optimizes cerebral venous drainage while preventing excessive intracranial pressure (ICP) changes that could impair perfusion.
White blood cell count. WBC count may be monitored for infection, but immediate concerns after brain surgery focus on neurological status and cerebral perfusion rather than infection unless symptoms of fever or worsening condition develop.
Pupil response. While pupil assessment is a key neurological parameter, it is more relevant for clients at risk of brain herniation or severe ICP elevation. In this case, monitoring level of consciousness and cerebral perfusion pressure takes priority.
Deep tendon reflexes. Reflex testing is not a primary concern after brain surgery unless there are signs of spinal cord involvement or a progressive neurological disorder. Monitoring motor function and speech ability is more relevant.
Myasthenia gravis. Myasthenia gravis is an autoimmune neuromuscular disorder that causes muscle weakness but is unrelated to brain tumor removal.
Cushing response. Cushing's response is a late sign of increased intracranial pressure (ICP), characterized by hypertension, bradycardia, and irregular respirations. The client has no signs of worsening ICP at this time.
Hydrocephalus. Hydrocephalus is excess cerebrospinal fluid (CSF) accumulation, which typically requires a shunt or external ventricular drain (EVD). There is no indication of CSF buildup in this client.

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Correct Answer is A

Explanation

A. Prepare for oral intubation. The client is in severe respiratory distress with oxygen saturation at 88% despite receiving 100% oxygen via a nonrebreather mask. This suggests respiratory failure, likely due to a pulmonary embolism (PE), a known complication following bariatric surgery. Immediate intubation and mechanical ventilation are necessary to prevent further hypoxia and respiratory collapse.
B. Apply leg compression hose. While deep vein thrombosis (DVT) prophylaxis is essential for postoperative bariatric patients, it is not the priority in an acute emergency. Compression devices help prevent clots but do not treat an existing life-threatening pulmonary embolism.
C. Maintain head of bed at 45°. Elevating the head of the bed can help with breathing, but it will not significantly improve oxygenation in a client already failing on 100% oxygen. The priority is to secure the airway with intubation to provide controlled ventilation.
D. Administer an anticoagulant. Anticoagulation is a key treatment for pulmonary embolism, but it does not immediately improve oxygenation or stabilize respiratory function. In a hemodynamically unstable client with severe hypoxia, securing the airway takes priority before initiating anticoagulation therapy.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Explanation

Compensated respiratory acidosis occurs when the lungs retain CO₂, causing acidosis, but the kidneys compensate by increasing bicarbonate (HCO₃⁻) levels. In this case, the pH is low, and the PaCO₂ is within normal limits, which does not indicate a respiratory issue or compensation. Compensation would require an elevated HCO₃⁻, which is not provided in the lab results.
Compensated metabolic acidosis would require a low pH with a decreased PaCO₂, as the respiratory system compensates by increasing ventilation (hyperventilation) to "blow off" CO₂. Since the PaCO₂ in this case is within normal limits, no significant respiratory compensation has occurred yet, making this uncompensated metabolic acidosis instead.
Uncompensated respiratory acidosis would present with a low pH and an elevated PaCO₂ (>45 mmHg) due to inadequate ventilation and CO₂ retention. Since the PaCO₂ here is 37 mmHg (within normal range), respiratory acidosis is unlikely. The metabolic component, rather than a respiratory problem, is driving the acidosis.
Uncompensated metabolic acidosis is characterized by a low pH (7.23) and a normal PaCO₂ (37 mmHg), indicating a primary metabolic problem without sufficient respiratory compensation. In diabetic ketoacidosis (DKA), the lack of insulin results in fat breakdown and ketone production, leading to a drop in pH and metabolic acidosis. This client likely has DKA due to their history of type 1 diabetes and the lack of insulin administration.
Kussmaul respirations are a compensatory response to metabolic acidosis, seen in conditions like DKA. However, they do not cause acidosis; instead, they are the body's attempt to correct it by exhaling CO₂. Since the ABG shows normal PaCO₂, there is no strong evidence of hyperventilation, suggesting compensation has not yet occurred.
Starvation can lead to ketoacidosis due to prolonged fasting and fat metabolism, producing ketones. However, in type 1 diabetes, the primary issue is no insulin production, not caloric deprivation. The severity of metabolic acidosis in this client is more likely due to insulin deficiency rather than starvation.
Tissue hypoxia leads to lactic acidosis, which results from anaerobic metabolism. This can be seen in conditions like sepsis or shock. However, in this case, the client has type 1 diabetes, and the more likely cause of acidosis is ketoacidosis due to insulin deficiency rather than hypoxia.
A lack of insulin in type 1 diabetes prevents glucose uptake, forcing the body to break down fat, leading to ketone formation and metabolic acidosis. This matches the clinical scenario of a patient with a history of type 1 diabetes, hyperglycemia >500 mg/dL, and metabolic acidosis.

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Naxlex Comprehensive Predictor Exams

A client who had gastric bypass surgery 3 days ago is admitted to the intensive care unit (ICU) with shortness of breath and chest pain. The client has a 100% nonrebreather mask with an oxygen saturation of 88%. Which intervention should the nurse implement?

Correct Answer is A

Explanation

Exhibits Drag one condition and one client finding to complete the sentence(s). Based on the ABG values, the nurse knows that the client has dropdownrelated todropdown

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Explanation

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