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
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B. Blood pH levels can indicate acid-base imbalances, but they do not specifically inform the nurse about the presence of infection.
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D. White blood cell (WBC) count is critical in assessing for infection, as an elevated WBC count can indicate the presence of an infection, particularly in a client with significant burns who is at increased risk for sepsis.
Correct Answer is D
Explanation
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