The nurse is assessing a client in the immediate post-operative setting. Which of the following finding requires priority intervention to prevent long-term complications?

Patient's refusal to cough, deep breathe, and use their incentive spirometer due to pain

Urine output of 40 mL/hr and clear yellow after having their Foley catheter removed

Patient ambulating short distances and performing range of motion exercises alter pain is controlled

Hypoactive bowel sounds 2 hours post-operative.

Answer and Explanation

The Correct Answer is A

A) Patient's refusal to cough, deep breathe, and use their incentive spirometer due to pain:
The patient’s refusal to perform these respiratory exercises could lead to serious complications such as atelectasis, pneumonia, and other respiratory issues. Coughing, deep breathing, and using the incentive spirometer are essential to prevent postoperative respiratory complications, especially if the patient is at higher risk for lung issues due to immobility or anesthesia. This needs immediate intervention to ensure the patient understands the importance of these activities and to address the pain issue, potentially with additional pain management or support.

B) Urine output of 40 mL/hr and clear yellow after having their Foley catheter removed:
A urine output of 40 mL/hr is within normal limits for a post-operative patient, and the clear yellow color indicates that the urine is not concentrated or indicative of infection. While monitoring urine output is important postoperatively, this finding suggests adequate renal function and does not indicate an immediate risk for long-term complications.

C) Patient ambulating short distances and performing range of motion exercises after pain is controlled:
Early ambulation and range of motion exercises are encouraged after surgery to promote circulation, prevent blood clots, and support overall recovery. It indicates that the patient is progressing in their recovery and actively participating in post-operative rehabilitation, which is a positive sign and does not need urgent intervention.

D) Hypoactive bowel sounds 2 hours post-operatively:
This is expected immediately after surgery, especially if the patient underwent abdominal surgery or received general anesthesia, which can temporarily reduce bowel motility. Hypoactive bowel sounds within the first few hours post-surgery are a normal response to anesthesia and do not require urgent intervention. The nurse should continue to monitor the patient’s bowel function, but this finding is not a priority in the immediate postoperative period.

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Correct Answer is ["7"]

Explanation

Given:

Desired dose: Amoxicillin 350 mg PO

Available concentration: Amoxicillin 250 mg/5 ml

To find:

Volume to administer (in ml)

Step 1: Set up the proportion

We can use the following proportion to solve the problem:

(Desired dose) / (Available concentration) = Volume to administer

Step 2: Substitute the values

Plugging in the given values, we get:

(350 mg) / (250 mg/5 ml) = Volume to administer

Step 3: Simplify

To simplify, we can invert the denominator and multiply:

(350 mg) x (5 ml / 250 mg) = Volume to administer

The "mg" units cancel out, leaving us with:

(350 x 5 ml) / 250 = Volume to administer

Step 4: Calculate

Performing the multiplication and division, we get:

1750 ml / 250 = Volume to administer

1 ml = Volume to administer

A. Recent thoracic surgery within the past week B. Uncontrolled hypertensive crisis C. Age over 65 years D. Head trauma with active cerebral hemorrhage

Correct Answer is C

Explanation

A. Recent thoracic surgery within the past week:
Recent surgery, especially in the thoracic region, is a contraindication for the use of tissue plasminogen activator (tPA) in stroke treatment. tPA is a thrombolytic agent that dissolves clots, but it also increases the risk of bleeding, including in areas where surgery has recently occurred. Using tPA in this situation can potentially lead to life-threatening bleeding complications.

B. Uncontrolled hypertensive crisis:
Uncontrolled hypertension is a contraindication for tPA. High blood pressure can increase the risk of hemorrhagic transformation (bleeding into the brain) when using thrombolytic therapy like tPA. A hypertensive crisis (typically systolic BP > 185 mmHg or diastolic BP > 110 mmHg) must be managed and brought under control before administering tPA to minimize the risk of bleeding complications.

C. Age over 65 years:
While age over 65 years may increase the risk of complications from tPA, it is not an absolute contraindication for its use. Guidelines for tPA administration in stroke patients typically focus more on factors like time from symptom onset (usually within 4.5 hours), the presence of contraindications like recent surgery or uncontrolled hypertension, and the overall clinical condition. Age itself is not a reason to withhold tPA unless other risk factors are present.

D. Head trauma with active cerebral hemorrhage:
Head trauma with active cerebral hemorrhage is a definitive contraindication for tPA. Since tPA is a clot-busting drug, it can worsen bleeding in the brain, especially in cases where there is ongoing hemorrhage from trauma. This significantly increases the risk of severe neurological damage and even death, so tPA should not be administered in such situations.

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The nurse is assessing a client in the immediate post-operative setting. Which of the following finding requires priority intervention to prevent long-term complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)

Correct Answer is ["7"]

Explanation

Which of the following is not a contraindication for the use of tissue plasminogen activator (PA) in the treatment of stroke?

Correct Answer is C

Explanation

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