The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?
Administer IV fluid bolus as prescribed by the healthcare provider.
Encourage the client to splint the Incision with a pillow to cough and deep breathe.
Medicate for pain and monitor vital signs according to protocol.
Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter.
The Correct Answer is C
C.Although postoperative pain can cause a similar presentation, pain management is not the priority intervention.
D. The client's vital signs of tachycardia, tachypnea, and elevated blood pressure suggest potential respiratory distress or inadequate oxygenation following the thoracotomy. Applying oxygen at a high flow rate via a non-rebreather mask can help improve oxygenation and support the client's respiratory function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. SIADH is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. Fluid restriction is a key component of treatment for SIADH to restore serum sodium levels to normal. Maintaining the prescribed fluid restriction is important for preventing further dilution of serum sodium and promoting continued improvement in the client's condition.
A. Withholding the next scheduled dose of treatment may not be appropriate solely based on a mild increase in serum sodium level. While syndrome of inappropriate antidiuretic hormone (SIADH) can lead to hyponatremia (low sodium levels) due to excessive water retention, an increase in serum sodium within a narrow range may not necessarily warrant withholding treatment.
C. Assessing for increasing fluid volume overload may be relevant in the context of managing SIADH and monitoring the client's response to treatment. However, an increase in serum sodium level from 120 mEq/L to 125 mEq/L suggests a trend towards correction of hyponatremia rather than worsening fluid volume overload.
D. Increasing the frequency of neurologic checks to every 2 hours may not be necessary solely based on a mild increase in serum sodium level from 120 mEq/L to 125 mEq/L.
Correct Answer is B
Explanation
B. Wearing wrist braces or splints at night can help alleviate symptoms of carpal tunnel syndrome by keeping the wrists in a neutral position and reducing pressure on the median nerve. This can help decrease pain and tingling sensations that often worsen at night due to positioning during sleep.
A. While it is important for the client to communicate changes in symptoms to their healthcare provider, worsening pain and tingling at night in bilateral carpal tunnel syndrome is a common symptom and may not require immediate medical intervention.
C. Elevating the hands on two pillows at night may help reduce swelling and alleviate symptoms in some individuals, but it is not specifically indicated for managing carpal tunnel syndrome.
D. Cold compresses may provide temporary relief of symptoms such as pain and inflammation, but they are not typically recommended as a primary treatment for carpal tunnel syndrome, especially before bedtime.
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