The nurse is assessing a client in the post-anesthesia care unit. The client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented x 3 and the skin is pale and damp. The client denies complaints of pain. What intervention should the nurse implement first?

Start an IV of DSNS with 40 mEq KCI at 125 mL/hr

Elevate the feet and lower the head

Call the surgeon and report the vital signs

Monitor the vital signs every 15 minutes

Answer and Explanation

The Correct Answer is B

A. Start an IV of DSNS with 40 mEq KCI at 125 mL/hr: Starting an IV is important but may not be the immediate first step. The client's symptoms suggest hypotension, likely due to hypovolemia, which needs immediate positional intervention before fluid administration.
B. Elevate the feet and lower the head: This position, known as the Trendelenburg position, helps increase venous return to the heart and can quickly improve blood pressure and perfusion to vital organs. It is an immediate intervention for hypotension.
C. Call the surgeon and report the vital signs: While important, calling the surgeon is not the first intervention. Immediate action to stabilize the client's condition is necessary before notifying the healthcare provider.
D. Monitor the vital signs every 15 minutes: Monitoring is important, but it is not an immediate intervention. The nurse must first address the client's low blood pressure and symptoms of hypoperfusion before continuing regular monitoring.

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Correct Answer is A

Explanation

A. Warfarin (Coumadin): This is the correct choice. Warfarin is an anticoagulant that increases the risk of bleeding during and after surgery. The surgeon needs to be notified to consider holding the medication and to adjust the surgical plan if necessary.
B. Gabapentin (Neurontin): While important for pain management, it does not significantly impact surgical procedures or bleeding risk.
C. Xanax (Alprazolam): This medication is a benzodiazepine used for anxiety, which might be relevant for preoperative anxiety but does not require immediate notification of the surgeon.
D. Atenolol (Tenormin): This beta-blocker is used for hypertension and heart conditions but does not require immediate notification of the surgeon unless there are specific cardiac concerns related to surgery.

A. Discontinue use of supplemental oxygen B. Encouraging use of incentive spirometer C. Implement fluid restrictions D. Administering an antitussive agent

Correct Answer is B

Explanation

A. Discontinue use of supplemental oxygen: This option is incorrect because supplemental oxygen is used to increase the oxygen levels in the blood, which is not directly related to addressing respiratory acidosis. In respiratory acidosis, the problem is primarily with the elimination of CO2 rather than oxygenation.
B. Encouraging use of incentive spirometer: This is the correct choice as using an incentive spirometer helps improve lung expansion and promotes alveolar ventilation, which aids in reducing CO2 levels in the blood, thereby addressing respiratory acidosis.
C. Implement fluid restrictions: This option is not suitable because fluid restrictions do not directly address the underlying issue of respiratory acidosis. Fluid restrictions might be necessary for other conditions, but they are not effective in correcting respiratory acid-base imbalances.
D. Administering an antitussive agent: This is incorrect because antitussive agents suppress cough reflexes, which can be counterproductive. In respiratory acidosis, coughing is often a protective mechanism to help clear secretions, so suppressing it may worsen the acid-base imbalance.

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The nurse is assessing a client in the post-anesthesia care unit. The client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented x 3 and the skin is pale and damp. The client denies complaints of pain. What intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is taking a medication history of a client scheduled for surgery the next morning. Which medication requires the nurse to immediately notify the surgeon?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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