A client has been admitted to the Post Anesthesia Care Unit (PACU) after a completing electroconvulsant therapy (ECT) treatment. Which action will the nurse perform first?
Assist the client from the stretcher to a wheelchair
Orient the client and offer reassurance
Encourage the client to drink some fluids
Assess vital signs and orient client to the PACU environment
The Correct Answer is D
A. Assist the client from the stretcher to a wheelchair: Immediately after electroconvulsive therapy (ECT), the client is still recovering from anesthesia and may experience confusion, drowsiness, or muscle weakness. Transferring the client prematurely poses a fall risk and is not appropriate as the first action.
B. Orient the client and offer reassurance: While reorientation and reassurance are important aspects of post-ECT care, safety and physiological stability must be assessed first. This action should follow an initial assessment of vital signs and level of consciousness.
C. Encourage the client to drink some fluids: Offering fluids too soon after ECT is inappropriate because the client may have impaired swallowing reflexes from anesthesia or sedation. Ensuring the airway is clear and the client is fully alert must precede oral intake.
D. Assess vital signs and orient client to the PACU environment: The priority after any procedure involving anesthesia is to assess vital signs to ensure hemodynamic stability and monitor for complications. Once stable, the nurse can begin to orient the client, which is often needed after ECT due to temporary disorientation or memory lapses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
Volume ordered is 1 L.
Convert the total volume to milliliters (mL)
1 L = 1000 mL.
Total volume in mL = 1 L × 1000 mL/L = 1000 mL
Total infusion time = 5 hours
Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Total volume (mL) / Total infusion time (hours)
= 1000 mL / 5 hours
= 200
The appropriate setting is 200 mL/hr.
Correct Answer is B
Explanation
A. "All patients with this disorder have a genetic defect which causes it.": Restrictive cardiomyopathy is not primarily a genetic disorder. While there may be rare familial forms, most cases are acquired, often secondary to systemic diseases, making this statement inaccurate and misleading.
B. "There are many theories about its development but amyloidosis in your history is a probable cause.": This is the most accurate response. Restrictive cardiomyopathy is commonly associated with infiltrative diseases such as amyloidosis, hemochromatosis, and sarcoidosis, which impair ventricular filling due to stiff, non-compliant myocardium.
C. "You probably had a silent heart attack which caused this disorder.": Silent myocardial infarctions can contribute to ischemic cardiomyopathy, typically leading to dilated, not restrictive, changes in the myocardium. They are not a primary cause of restrictive cardiomyopathy.
D. "Your long-standing hypertension caused this disorder.": Chronic hypertension more commonly leads to left ventricular hypertrophy and may contribute to diastolic heart failure, but it is not a typical cause of restrictive cardiomyopathy.
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