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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Correct Answer is D
Explanation
A. Throbbing pain can be a common response after a fracture and cast application but does not necessarily indicate an emergency situation.
B. Circumferential edema could suggest complications, but it is not as immediately concerning as the vascular status of the limb.
C. An increased temperature in the lower extremity could indicate inflammation or infection, but it does not require immediate intervention compared to signs of impaired circulation.
D. A pale foot with sluggish capillary refill suggests compromised blood flow, which is a medical emergency requiring immediate assessment and intervention to prevent ischemia or compartment syndrome.
Correct Answer is B
Explanation
A. Eating a protein snack before exercising can help prevent hypoglycemia, but this may not be necessary for every individual and does not address the overall management of diabetes.
B. Understanding the importance of receiving an influenza vaccine annually is crucial for clients with diabetes, as they are at higher risk for complications from influenza and other infections.
C. While it is important to monitor alcohol consumption, the statement may not indicate full understanding of how alcohol can affect blood glucose levels and the potential need for individualized guidance.
D. While using salt, herbs, and spices can enhance food flavor, it does not specifically address diabetes management, particularly regarding sodium intake for individuals at risk for hypertension.