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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Sinus Bradycardia, with First Degree AV block, Rate 40: The rhythm strip shows regular P waves, each followed by a QRS complex, indicating a sinus rhythm. The PR interval is prolonged (greater than 0.20 seconds) but remains consistent across all beats. This confirms a first-degree AV block. The ventricular rate is approximately 40 bpm, consistent with sinus bradycardia.

B. Second Degree AV block – Mobitz I, Rate 40: Mobitz I (Wenckebach) is characterized by a progressively lengthening PR interval followed by a dropped QRS complex. This pattern is not seen here; the PR intervals are consistently prolonged.

C. Second Degree AV block – Mobitz II, Rate 40: Mobitz II involves intermittent dropped QRS complexes without progressive PR prolongation. In the strip, no QRS complexes are missing, ruling out Mobitz II.

D. Third Degree Heart Block, Rate 40: In complete heart block, there is no relationship between P waves and QRS complexes (AV dissociation). Here, the P waves are consistently followed by QRS complexes, indicating intact conduction, even if delayed. This therefore is not a third-degree block.

A. Ensure all tubing connections are tightened B. Apply a pressure dressing to the insertion site C. Perform an Allen's test D. Obtain a portable x-ray to confirm placement

Correct Answer is A

Explanation

A. Ensure all tubing connections are tightened: Tight tubing connections are critical in preventing accidental disconnection, which can result in rapid blood loss and air embolism. Arterial lines are under high pressure, so securing all connections is a top priority to ensure patient safety and maintain line integrity.

B. Apply a pressure dressing to the insertion site: A transparent occlusive dressing not a pressure dressing is used for arterial lines to allow for site visualization and reduce the risk of infection. A pressure dressing could obscure signs of bleeding or compromise the catheter’s position.

C. Perform an Allen's test: Allen’s test is performed prior to radial arterial line insertion to assess collateral circulation via the ulnar artery for preventing ischemic complications if the radial artery is compromised. Performing the test afterward does not prevent complications and is no longer relevant once the catheter is placed.

D. Obtain a portable x-ray to confirm placement: X-rays are used to confirm the placement of central lines, not peripheral arterial lines like the radial line. Arterial line placement is confirmed by waveform analysis and blood return, not imaging.

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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?

Nursing Test Bank

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