A client is being transferred to the medical-surgical unit from the PACU after receiving general anesthesia for a procedure. Which of the following actions is the priority for the nurse when the client arrives on the unit?

Assess airway patency

Check the dressing to assess bleeding.

Check tubes or drains for patency.

Assess all vital signs.

Answer and Explanation

The Correct Answer is A

A. Assess airway patency: Ensuring the airway is patent is the highest priority because compromised airway patency can lead to life-threatening respiratory complications. This is the first step in the ABCs (Airway, Breathing, Circulation) of emergency and postoperative care.
B. Check the dressing to assess bleeding: While assessing the dressing for bleeding is important, it is secondary to ensuring the client has a patent airway. Uncontrolled bleeding can be addressed after confirming the client can breathe adequately.
C. Check tubes or drains for patency: Checking tubes and drains for patency is also important, but it should be done after ensuring the client's airway is secure. This step is essential for preventing complications but is not as immediately critical as airway assessment.
D. Assess all vital signs: Assessing vital signs is crucial, but it follows after ensuring airway patency. Vital signs provide comprehensive information about the client's status, but an obstructed airway must be addressed first to ensure effective breathing and oxygenation.

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Correct Answer is C

Explanation

A. Imitation of the lining of the stomach: This is not a common complication related to calcium supplementation or fluid intake.
B. Mobilization of calcium from bones: Drinking fluids does not affect the mobilization of calcium from bones; this is more related to bone health and calcium metabolism.
C. Developing kidney stones: Adequate fluid intake helps prevent kidney stones, which can form when there is excess calcium in the urine. High calcium levels can lead to stone formation if not properly managed with sufficient hydration.
D. Developing muscle cramps: While calcium plays a role in muscle function, fluid intake primarily helps with kidney function and preventing stone formation rather than directly preventing muscle cramps.

A. Reddish streak proximal to the insertion site B. Skin is pale and taut C. The vein is firm and cord-like D. IV fluid leaking from insertion site E. Warmth at the insertion site

Correct Answer is ["B","D","E"]

Explanation

A. Reddish streak proximal to the insertion site: This indicates phlebitis, not infiltration.
B. Skin is pale and taut: This indicates infiltration as fluid accumulates in the surrounding tissue, causing the skin to appear pale and tight.
C. The vein is firm and cord-like: This is typically a sign of phlebitis or thrombophlebitis, not infiltration.
D. IV fluid leaking from insertion site: This is a sign of infiltration where fluid has leaked out of the vein into the surrounding tissue.
E. Warmth at the insertion site: This can indicate infiltration or inflammation, depending on other symptoms present.

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A client is being transferred to the medical-surgical unit from the PACU after receiving general anesthesia for a procedure. Which of the following actions is the priority for the nurse when the client arrives on the unit?

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Naxlex Comprehensive Predictor Exams

A nurse is providing education in a community setting to several clients taking daily calcium supplements and encourages them to drink 2,500 mL of fluid daily. The nurse explains that this intervention is important to prevent which complication?

Correct Answer is C

Explanation

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

Correct Answer is ["B","D","E"]

Explanation

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Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

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