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.

Answer and Explanation

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.

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Naxlex Comprehensive Predictor Exams

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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 {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

Inflammation and discoloration are key symptoms of an acute gout attack.

Inflammation: This occurs when urate crystals in the joints trigger an immune response, causing swelling, redness, warmth, and significant pain.
Discoloration: Typically presents as redness over the affected joint, due to increased blood flow and inflammation, highlighting the body's response to the crystal deposits.

These symptoms help healthcare providers identify and treat gout, focusing on reducing inflammation and managing uric acid levels.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?