The practical nurse (PN) is caring for a client scheduled for a bronchoscopic procedure. After the charge nurse administers the IV sedative, which action should the PN implement?
Reinforce expected outcomes of surgery.
Determine if the client needs to void.
Auscultate all lung fields.
Monitor blood pressure.
The Correct Answer is D
Choice A reason: Reinforcing the expected outcomes of surgery is important in the preoperative phase to ensure the client understands the procedure, risks, and expected results. However, once the IV sedative has been administered, the client may be in a sedated state and may not be able to retain this information effectively. Therefore, this action is more appropriate before administering the sedative rather than after. The focus should shift to monitoring the client's vital signs and ensuring their safety.
Choice B reason: Determining if the client needs to void is generally part of the preoperative preparations to ensure that the bladder is empty, reducing the risk of complications during the procedure. While it is important, this step should be completed before administering the sedative to ensure the client is alert and able to communicate their needs. Once sedated, the client’s immediate needs should focus on their vital signs and overall stability.
Choice C reason: Auscultating all lung fields is a valuable assessment to ensure the client has clear airways and adequate ventilation. However, once the client is sedated, continuous monitoring of vital signs, including respiration, is more critical. Auscultating lung fields might be appropriate before the procedure to establish a baseline, but it is not the immediate priority after administering sedation.
Choice D reason: Monitoring blood pressure is the most crucial action to implement after administering the IV sedative. Sedatives can cause changes in cardiovascular stability, including hypotension or hypertension. Continuous monitoring of blood pressure helps detect any adverse effects of the sedation and ensures prompt intervention if necessary. Maintaining stable blood pressure is vital for the safety and well-being of the client during and after the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Yellow urine can be a sign of dehydration or other conditions, but it is not typically associated with cholelithiasis. While it is important to monitor urine color, it does not indicate a direct complication of gallstones.
Choice B reason: Restlessness can be caused by various factors, including discomfort or anxiety. However, it is not a specific indicator of a complication related to cholelithiasis. The practical nurse should assess the cause of restlessness, but it does not warrant immediate reporting to the charge nurse in the context of gallstones.
Choice C reason: Persistent nausea can be a symptom of cholelithiasis, especially if the gallstones are causing a blockage in the bile ducts. While nausea should be monitored and managed, it is not the most critical finding that requires immediate reporting to the charge nurse.
Choice D reason: Clay-colored stools are a significant finding that indicates a possible bile duct obstruction. When bile flow is blocked, it can result in pale or clay-colored stools. This is a critical sign that requires immediate attention and reporting to the charge nurse, as it suggests a serious complication that needs prompt intervention.
Correct Answer is C
Explanation
Choice A reason: Lymph nodes are important components of the immune system and play a crucial role in filtering harmful substances and housing lymphocytes. While HIV/AIDS can affect lymph nodes, it is not the primary target of the virus.
Choice B reason: The spleen is another vital organ in the immune system that helps filter blood and fight infections. However, it is not the specific target of HIV.
Choice C reason: T cells, specifically CD4+ T cells, are the main target of HIV (the virus that causes AIDS). HIV infects and destroys these cells, leading to a weakened immune system. The progressive loss of CD4+ T cells impairs the body's ability to fight off infections and certain cancers, which is characteristic of AIDS.
Choice D reason: B cells are responsible for producing antibodies and play a key role in the humoral immune response. While HIV/AIDS can indirectly impact B cell function due to the overall compromised immune system, B cells are not the primary cells affected by the virus.
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