The nurse is caring for a client in the postanesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the vital signs as a heart rate of 140 beats/minute, respirations 26 breaths/minute, and a blood pressure 140/90 mm Hg. Which intervention is most important for the nurse to implement?
Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
Medicate for pain and monitor vital signs according to protocol.
Administer intravenous fluid bolus as prescribed by the healthcare provider.
Encourage the client to splint the incision with a pillow to cough and deep breathe.
The Correct Answer is A
A. The elevated heart rate and respirations suggest the client may be experiencing hypoxia, especially following a thoracotomy. Administering oxygen will help improve oxygen saturation levels and address potential respiratory distress.
B. While pain management is essential, the immediate concern is ensuring adequate oxygenation.
C. Administering IV fluids may be necessary but is secondary to ensuring the client's oxygenation.
D. Encouraging the client to splint and cough is important for preventing complications but does not address the immediate issue of vital signs indicating possible respiratory compromise.
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Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The nurse should teach the client that gout attacks can be limited by keeping a diet that is low purine and a lifestyle free from alcohol.
Rationale:
- Low Purine Diet: Foods high in purines (like red meats, certain seafood, and organ meats) increase uric acid levels, which can trigger gout attacks. A low purine diet helps reduce uric acid levels and may prevent future flare-ups.
- Avoiding Alcohol: Alcohol, especially beer, can increase uric acid levels and is a known risk factor for gout attacks. By avoiding alcohol, the client reduces the likelihood of aggravating their condition.
Correct Answer is C
Explanation
A. Oxycodone is an opioid analgesic used for moderate to severe pain management but is not typically the first-line medication in acute coronary syndrome scenarios.
B. Fentanyl is a potent opioid that may be used for severe pain; however, morphine is more commonly used in emergency situations for chest pain related to potential myocardial infarction.
C. Morphine is commonly used in emergency departments for the management of acute chest pain, particularly when associated with myocardial ischemia. It helps reduce pain and anxiety, lowers myocardial oxygen demand, and has vasodilatory effects that can alleviate the burden on the heart.
D. Hydromorphone is another opioid analgesic but is not usually the preferred choice for chest pain in the acute setting compared to morphine.
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