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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

C. A pale right foot with sluggish capillary refill suggests compromised blood flow to the foot, which may indicate arterial insufficiency or compartment syndrome. Compromised circulation can lead to tissue ischemia and necrosis if not promptly addressed.
A. While increased temperature to the lower extremity may indicate inflammation or infection, it is not as urgent as the finding of compromised circulation.
B. Circumferential edema of the right foot may occur due to trauma or inflammation and can contribute to increased pressure within the leg compartment, potentially leading to compartment syndrome. While edema should be monitored closely, the finding of pale color and sluggish capillary refill is more indicative of compromised circulation and requires immediate intervention.
D. Throbbing right leg pain is a common symptom following a fracture and cast application and may be managed with pain medication. While it should be addressed, it is not as urgent.

A. Methotrexate has less harmful side effects than aspirin. B. Methotrexate helps to reduce the side effects of the aspirin therapy. C. Methotrexate enhances the effectiveness of the aspirin. D. Methotrexate slows the disease progression while aspirin controls the symptoms.

Correct Answer is D

Explanation

D Methotrexate is a disease-modifying antirheumatic drug (DMARD) commonly used in the treatment of RA to slow down the progression of joint damage and reduce inflammation. Aspirin, on the other hand, is often used to manage symptoms such as pain and inflammation. Combining these two medications addresses both the underlying disease process and symptom control, respectively, in the management of RA
A While both methotrexate and aspirin have potential side effects, they affect different aspects of rheumatoid arthritis treatment. Methotrexate is primarily used to slow disease progression, while aspirin is used for symptom management.
B Methotrexate and aspirin do not directly interact to reduce each other's side effects.
C While both methotrexate and aspirin have their own roles in the treatment of rheumatoid arthritis, there is no evidence to suggest that methotrexate enhances the effectiveness of aspirin. They work through different mechanisms and target different aspects of RA management.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

Methotrexate is prescribed for a client with rheumatoid arthritis (RA) who is also taking aspirin. Which is the best explanation for the nurse to provide as to why a second medication has been added?

Correct Answer is D

Explanation

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?

A client receives a prescription for 1 L of lactated Ringers to be infused IV over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?

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?

The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)?

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?