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Exhibits

A client is brought to post anesthesia care unit (PACU) after an invasive procedure. Based on the two sets of vital signs in the chart tab, which action is most appropriate by the nurse?

Continue monitoring the vitals

inform the surgeon about the increase in temperature

increase intravenous fluid rates

inform the surgeon about the decrease in blood pressure

Answer and Explanation

The Correct Answer is A

A. The changes in vital signs are within expected ranges post-procedure, so continued monitoring is appropriate.

B. A temperature increase to 99°F is not significant and does not require immediate reporting.

C. No signs of hypovolemia or dehydration warrant increasing IV fluids.

D. A blood pressure decrease to 112/72 mm Hg is minimal and not concerning.

Nursing Test Bank

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Correct Answer is C

Explanation

A. A blood pressure of 120/84 mm Hg is within normal limits and does not require immediate intervention.

B. Hypoactive bowel sounds are a common side effect of sedation and not an immediate concern.

C. A respiratory rate of 9 breaths per minute indicates respiratory depression, which is a life-threatening side effect of Propofol. Immediate intervention is required to maintain oxygenation.

D. Urine output of 90 mL over 2 hours is adequate and does not indicate acute distress.

A. Cover the bowel with wet sterile gauze B. Assist the client into a low-Fowler's position with knees flexed C. Assist the client into a side-lying position with knees flexed D. Retrieve the crash cart from the nursing station E. Call for assistance F. Measure the client's inspiratory volume via incentive spirometer

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

Explanation

A: Covering the bowel with sterile gauze moistened with saline protects the exposed tissue and prevents it from drying out.

B: A low-Fowler's position with knees flexed reduces strain on the abdomen and minimizes further protrusion.

C: A side-lying position does not relieve strain on the abdominal incision as effectively as a low-Fowler’s position.

D: Retrieving the crash cart is unnecessary unless there is evidence of impending cardiopulmonary arrest.

E: Calling for assistance is essential to notify the surgical or medical team promptly.

F: Measuring inspiratory volume is irrelevant in this scenario and delays appropriate intervention.

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Exhibits A client is brought to post anesthesia care unit (PACU) after an invasive procedure. Based on the two sets of vital signs in the chart tab, which action is most appropriate by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving Propofol for sedation during a medical procedure. Which assessment finding should the nurse prioritize when monitoring the client's response to Propofol?

Correct Answer is C

Explanation

The nurse is caring for a client in the immediate post-operative period. On assessment, the nurse notes the client's bowels are protruding from the abdominal incision. Which intervention(s) by the nurse are most appropriate at this time? (Select All That Apply]

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

Explanation

A nurse is caring for several clients in the post-operative unit. Which client should the nurse see first?

A nurse is working in a preoperative unit. Which task is most appropriate to be delegated to unlicensed assistive personnel (UAP)?

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team?

Exhibits A client is brought to post anesthesia care unit (PACU) after an invasive procedure. Based on the two sets of vital signs in the chart tab, which action is most appropriate by the nurse?

A client is receiving diazepam prior to a procedure. Which side effect should the nurse be most concerned about?

A nurse is teaching a newly licensed nurse about anesthesia. The nurse should include that an epidural is an example of which of the following types of anesthesia?

A nurse is scheduling an older client for a surgical clearance appointment. Which intervention is best to reduce the risk of drug interactions for the client?

A nurse is caring for a client receiving fentanyl. On assessment, the client's respiratory rate is 8 breaths per minute. Which medication is appropriate at this time?

Exhibits

A client is brought to post anesthesia care unit (PACU) after an invasive procedure. Based on the two sets of vital signs in the chart tab, which action is most appropriate by the nurse?