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.

Answer and Explanation

The Correct Answer is B

A. Oxygen therapy is important in postoperative care, but the vital signs suggest the primary issue is uncontrolled pain rather than hypoxia. Tachycardia, tachypnea, and mild hypertension commonly indicate acute postoperative pain in PACU patients.

B. Severe pain after thoracotomy can cause significant sympathetic stimulation, leading to increased heart rate, respirations, and blood pressure. Prompt pain control is the priority because it helps stabilize vital signs and improves the ability to breathe deeply and effectively.

C. Fluid bolus is indicated when hypovolemia or shock is suspected, but there are no clear signs such as hypotension or poor perfusion in this case. Therefore, this intervention is not the priority.

D. Splinting and deep breathing are important for preventing atelectasis, but they do not address the immediate cause of the abnormal vital signs. The priority is to control pain so the client can effectively participate in these respiratory exercises.

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Correct Answer is B

Explanation

A. Latent hepatitis C is not an absolute contraindication for peritoneal dialysis, and patients with this condition can often undergo dialysis with appropriate precautions.

B. Crohn's disease with a history of colectomy poses a risk for peritoneal dialysis due to potential intra-abdominal adhesions and infection, which can complicate the procedure and increase the risk of peritonitis.

C. A history of nephrotic syndrome does not contraindicate peritoneal dialysis; patients with nephrotic syndrome may still be candidates depending on their overall kidney function and health status.

D. Type 2 diabetes mellitus is a common condition among patients needing dialysis and does not preclude the use of peritoneal dialysis, as long as blood sugar levels are managed effectively.

A. Select another finger. B. Apply pressure to the site. C. Assess radial pulse volume. D. Collect the blood sample.

Correct Answer is A

Explanation

A. Selecting another finger is the best action to prevent discomfort and ensure an accurate blood sample. The reddened and engorged tip may indicate that milking the finger caused bruising or altered blood flow, which can affect the glucose reading.

B. Applying pressure to the site may be appropriate after collecting a sample, but it does not address the issue of obtaining an accurate sample from an engorged finger.

C. Assessing radial pulse volume is not relevant in this situation and does not address the problem at hand.

D. Collecting the blood sample from a reddened and engorged finger could yield an inaccurate result, so it is better to select a different finger.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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?

Correct Answer is A

Explanation

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?

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?

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 caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instructions regarding skin care of the portal site should the nurse provide?

A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?