The nurse is caring for a client who had a bowel resection for colon cancer. The vital signs were stable during surgery. While in the post-anesthesia care unit (PACU) the client is sleepy but awakens easily. The pulse ox is 88%. What would be the priority action by the nurse?

Call a rapid response for more assistance

Administer naloxone 0.4 mg SQ and reassess

Check the temperature and apply warmed blankets

Encourage the client to take deep breaths

Answer and Explanation

The Correct Answer is D

A. Calling a rapid response may be necessary if the client's condition deteriorates, but it is not the immediate priority in this scenario where the client is still able to be aroused.
B. Administering naloxone is appropriate if there is suspicion of opioid overdose; however, the priority is to address the low oxygen saturation first with non-invasive measures.
C. Checking the temperature and applying warmed blankets may be important, but the immediate concern is the low oxygen saturation.
D. Encouraging the client to take deep breaths is the most appropriate immediate action to improve oxygen saturation levels and enhance ventilation, as the client is in a post-anesthesia state where respiratory depression can occur.

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Correct Answer is C

Explanation

A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.
B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.
C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.
D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.

Correct Answer is ["12"]

Explanation

Calculate the dilution factor of the insulin solution:
- Dilution factor = Total volume / Insulin units
- Dilution factor = 150 mL / 75 units
- Dilution factor = 2 mL/unit
Determine the volume of the insulin solution needed to deliver 6 units/h:
- Volume = Desired dosage * Dilution factor
- Volume = 6 units/h * 2 mL/unit
- Volume = 12 mL/h

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The nurse is caring for a client who had a bowel resection for colon cancer. The vital signs were stable during surgery. While in the post-anesthesia care unit (PACU) the client is sleepy but awakens easily. The pulse ox is 88%. What would be the priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?

Correct Answer is C

Explanation

A client is to receive a continuous infusion of IV Insulin at 6 units per hour. Pharmacy delivers a concentration of 75 units of regular insulin in 150 mL of NSS. At what rate should the nurse set the IV pump?

Correct Answer is ["12"]

Explanation

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