The nurse determines that an adult client who is admitted to the postanesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.8°C), a heart rate of 88 beats per minute, a respiratory rate of 14 breaths per minute, and a blood pressure of 94/68 mm Hg. Which intervention should the nurse implement first?

Check the blood pressure every five minutes for one hour

Take the client's temperature using another method

Raise the head of the bed to 60 to 90 degrees

Ask the client to cough and deep breathe

Answer and Explanation

The Correct Answer is B

Choice A reason: Checking the blood pressure every five minutes for one hour is important, especially if the blood pressure is unstable. However, this action does not address the immediate issue of the client’s low temperature, which needs to be verified and addressed promptly to prevent complications such as hypothermia.

Choice B reason: Taking the client's temperature using another method is crucial. The extremely low tympanic temperature reading may not be accurate, and confirming the client's core body temperature is essential. Hypothermia can lead to serious complications, including altered cardiovascular and respiratory function, and needs to be managed promptly.

Choice C reason: Raising the head of the bed to 60 to 90 degrees is not appropriate in this situation. Elevating the head of the bed is typically done to improve respiratory function or decrease intracranial pressure, but it does not address the potential issue of hypothermia indicated by the low temperature reading.

Choice D reason: Asking the client to cough and deep breathe is a good practice to prevent postoperative complications such as atelectasis, but it is not the priority intervention in this scenario. The immediate concern is verifying the client's temperature to rule out or address hypothermia.

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Correct Answer is A

Explanation

Choice A reason: Taking the client to the emergency department is crucial because missing a dialysis session can lead to severe complications such as fluid overload, high potassium levels, and other electrolyte imbalances. These conditions can be life-threatening and require immediate medical attention to stabilize the client.

Choice B reason: Applying home oxygen is not the most critical intervention in this scenario. While oxygen therapy might be necessary in some cases, it does not address the immediate risk of complications arising from missed dialysis.

Choice C reason: Ensuring that the client avoids salt intake for the rest of the day is important for managing fluid balance, but it is not the most urgent action needed in this situation. The client's lethargy and difficulty arousing indicate a more serious underlying issue that requires immediate medical evaluation.

Choice D reason: Checking for a thrill and bruit at the client's dialysis access site is important for assessing the patency of the access site, but it is not the most critical action in this scenario. The immediate concern is the client's lethargy and potential complications from missed dialysis, which necessitate emergency medical care.

A. Jugular vein distension B. Lower extremity edema C. Hepatomegaly D. Fatigue

Correct Answer is B

Explanation

Choice A reason: Jugular vein distension is often associated with right-sided heart failure, where the right ventricle fails to pump effectively, leading to increased pressure in the veins and fluid backup. While it can occur in advanced cases of left ventricular dysfunction, it is not as directly indicative as lower extremity edema.

Choice B reason: Lower extremity edema is a common finding in left ventricular dysfunction. When the left ventricle fails to pump blood efficiently, it leads to a buildup of fluid in the lungs and eventually in the extremities. This results in swelling, particularly in the lower legs and feet. This symptom is a key indicator of congestive heart failure.

Choice C reason: Hepatomegaly, or enlargement of the liver, is more commonly associated with right-sided heart failure due to congestion of blood flow in the liver. While it can occur in severe cases of left ventricular dysfunction, it is not as typical an initial finding as lower extremity edema.

Choice D reason: Fatigue is a non-specific symptom that can be associated with various conditions, including heart failure. However, it is not as immediately indicative of left ventricular dysfunction as lower extremity edema, which is more directly related to the underlying issue of fluid retention and heart failure.

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Naxlex Comprehensive Predictor Exams

A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client's spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?

Correct Answer is A

Explanation

An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

Correct Answer is B

Explanation

A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?

A client who had a C5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

A client who is experiencing a first gouty arthritis attack reports excruciating pain in the right great toe. The nurse inspects the inflamed joint and administers ibuprofen 800mg PO as prescribed. Which instruction should the nurse include in the discharge teaching?

The nurse has conducted a cancer prevention community education program. In evaluating the participants' understanding of the carcinogens, which statement indicates an accurate understanding?

A client with oral cancer is receiving radiotherapy (RT) prior to surgery. Which intervention should the nurse teach the client to implement in managing mucositis related to RT?