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: Administering a PRN prescription for an antiemetic is not the first action to take in this situation. Shaking and feelings of nausea and vomiting during a blood transfusion can indicate a possible transfusion reaction, which is a serious and potentially life-threatening event. While managing symptoms like nausea is important, the immediate priority is to stop the transfusion to prevent further complications.
Choice B reason: Flushing the IV tubing with sodium chloride is not the appropriate first step. Before addressing the IV line, it is crucial to stop the blood infusion to prevent any more blood from entering the client's system, which could exacerbate a potential transfusion reaction. After stopping the infusion, flushing the line can be considered to maintain IV access, but it is not the initial action to take.
Choice C reason: Notifying the healthcare provider is necessary, but it is not the first action to take. Immediate intervention is required to prevent further administration of the potentially problematic blood product. Once the infusion is stopped, the healthcare provider should be notified promptly so that appropriate assessments and interventions can be initiated.
Choice D reason: Turning off the blood infusion is the first and most critical action to take. This step immediately stops the administration of the blood product, preventing further exposure to the potential cause of the reaction. Once the infusion is stopped, the PN can then proceed to assess the client's vital signs, notify the healthcare provider, and follow the institution's protocol for managing transfusion reactions. Ensuring the client's safety by stopping the infusion is the top priority.
Correct Answer is A
Explanation
Choice A reason: Measuring intake and output while straining all urine is the priority action. This helps to monitor kidney function, assess fluid balance, and detect the passage of kidney stones. Straining urine can also catch any stones or fragments, which can be analyzed to determine their composition and guide further treatment.
Choice B reason: Reviewing foods that are high in oxalate is important for dietary management of kidney stones, but it is not the immediate priority. Dietary education is more relevant once the client's acute symptoms are managed and stabilized.
Choice C reason: Monitoring the client's serum calcium levels is important in the management of certain types of kidney stones, particularly those formed from calcium. However, this action is not as immediate a priority as measuring intake and output and straining urine to assess for stone passage.
Choice D reason: Encouraging the client to begin a weight loss program is beneficial for overall health and can reduce the risk of future kidney stones. However, it is not the immediate priority when treating an acute episode of kidney stones.
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