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 C

Explanation

Choice A reason: Wrapping the feet with warmed blankets may provide comfort and warmth, but it does not address the immediate concern of assessing the circulation status in the lower extremities. It is not the first action to take in this situation.

Choice B reason: Elevating the extremities on pillows can help reduce edema and improve circulation, but it should not be the first action taken. Assessing the pulses is crucial to determine the severity of the circulation issue and guide further interventions.

Choice C reason: Assessing pulses with a vascular doppler is the correct first action. Since the pedal pulses are not palpable, using a vascular doppler can help determine if there is any blood flow in the lower extremities. This assessment is essential to identify potential complications such as arterial occlusion or compromised circulation, which require immediate intervention.

Choice D reason: Evaluating edema for pitting can provide information about the extent of the swelling, but it does not address the immediate concern of assessing blood flow. Assessing pulses with a vascular doppler is a more critical first step to ensure the client's circulation status is evaluated accurately.

A. Overall fluid intake. B. Citrus fruit juices. C. Low-sodium sodas. D. Tea and hot chocolate.

Correct Answer is B

Explanation

Choice A reason: Overall fluid intake should not be limited. In fact, increasing fluid intake is generally recommended to help flush out the urinary system and prevent the formation of new stones. Adequate hydration is key to preventing urinary tract calculi.

Choice B reason: Citrus fruit juices, such as orange juice and grapefruit juice, should be limited because they can increase the acidity of the urine. High acidity can contribute to the formation of certain types of kidney stones, particularly uric acid stones. Limiting citrus fruit juices can help reduce the risk of stone recurrence.

Choice C reason: Low-sodium sodas are generally better than regular sodas, but it is important to note that many sodas, even low-sodium ones, contain high levels of phosphates and other substances that can contribute to kidney stone formation. While low-sodium sodas are a better option, the primary focus should be on overall healthy fluid choices.

Choice D reason: Tea and hot chocolate should be limited due to their oxalate content. Oxalates can bind with calcium in the urine to form calcium oxalate stones, which are the most common type of kidney stones. Limiting the intake of tea and hot chocolate can help reduce the risk of stone formation.

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Naxlex Comprehensive Predictor Exams

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

Correct Answer is C

Explanation

A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing fluid intake, the nurse should include which type of fluid limitation?

Correct Answer is B

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?

The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure?

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

Exhibits The nurse is stabilizing the client and preparing her for surgery. Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?