Question 92
A client is transferred to the Postanesthesia Care Unit (PACU) after surgery. The priority nursing intervention is:

Administering an antiemetic

Applying sequential compression devices

Assessing vital signs

Hanging the Lactated Ringers solution

Answer and Explanation

The Correct Answer is C

Choice A reason:
Administering an antiemetic is an important intervention in the PACU, especially if the patient is experiencing nausea or has a history of postoperative nausea and vomiting (PONV). However, it is not the first priority. Antiemetics work by blocking the neurotransmitters that trigger the vomiting reflex. Medications such as ondansetron or promethazine may be used.

Choice B reason:
Applying sequential compression devices is a preventive measure against deep vein thrombosis (DVT), which is a risk due to immobility after surgery. These devices help improve venous return from the lower limbs by applying intermittent pressure. While important, this intervention follows after the assessment of vital signs.

Choice C reason:
Assessing vital signs is the first and foremost priority when a patient is transferred to the PACU. Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, provide immediate information about the patient's hemodynamic status and can indicate the need for urgent interventions. Any evidence of respiratory or circulatory compromise requires immediate attention.

Choice D reason:
Hanging the Lactated Ringers solution is part of managing the patient's fluid status postoperatively. Lactated Ringers is an isotonic solution that helps to replace lost fluids and maintain electrolyte balance. While important for patient care, it is not the initial priority upon arrival in the PACU.

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Correct Answer is A

Explanation

Choice A Reason:
Dantrolene is used in the management of malignant hyperthermia, a life-threatening complication characterized by muscle rigidity and elevated temperature, often triggered by certain anesthetics. The patient's symptoms of muscle rigidity and brown urine, which may indicate myoglobinuria, along with elevated temperature and heart rate, are suggestive of this condition. Dantrolene acts by reducing calcium release from the sarcoplasmic reticulum of skeletal muscle, thereby reducing muscle contraction and metabolic demand.

Choice B Reason:
Metoprolol, a beta-blocker, is not the first-line treatment for symptoms suggestive of malignant hyperthermia. While it can reduce heart rate and blood pressure, it does not address the underlying pathophysiology of malignant hyperthermia and is not indicated in this scenario.

Choice C Reason:
Increasing the rate of lactated Ringer's solution is not the primary intervention for malignant hyperthermia. While maintaining hydration is important, it does not directly counteract the pathophysiological processes at play in malignant hyperthermia.

Choice D Reason:
While liver function tests can be important in assessing overall organ function post-operatively, they are not the immediate priority in a suspected case of malignant hyperthermia. The priority is to treat the acute and life-threatening symptoms first.

A. Urine negative for ketones. B. Sodium 135 mg/dL and Potassium 3.5 mEq/L. C. BUN 34 mg/dL and Creatinine 4.2 mg/dL. D. White blood cell count 12,000/mm³.

Correct Answer is C

Explanation

Choice A Reason
Urine negative for ketones is a normal finding and does not typically indicate an acute problem. Ketones in the urine can be a sign of uncontrolled diabetes or starvation, but their absence is expected in a well-nourished individual who is not in a state of diabetic ketoacidosis.

Choice B Reason
Sodium at 135 mg/dL and Potassium at 3.5 mEq/L are within normal ranges. The normal range for serum sodium is approximately 135-145 mEq/L, and for serum potassium, it is around 3.5-5.0 mEq/L. These values do not indicate an immediate concern for the patient with urosepsis.

Choice C Reason
A BUN of 34 mg/dL and Creatinine of 4.2 mg/dL are concerning. The normal range for BUN is approximately 6-20 mg/dL, and for Creatinine, it is about 0.6-1.2 mg/dL for males and 0.5-1.1 mg/dL for females. Elevated levels of BUN and Creatinine indicate impaired kidney function, which can be a complication of urosepsis and the nephrotoxic effects of gentamicin and vancomycin.

Choice D Reason
A white blood cell count of 12,000/mm³ is slightly elevated, which may be expected in a patient with an infection such as urosepsis. The normal range is approximately 4,500-11,000 WBCs/mm³. While this should be monitored, it does not require immediate reporting unless there is a significant change or it is outside the patient's baseline.

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Question 92 A client is transferred to the Postanesthesia Care Unit (PACU) after surgery. The priority nursing intervention is:

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a post-operative client and notices that the client's urine is brown and they are experiencing muscle rigidity. The vital signs are T: 102.5 F; HR: 112; RR: 20 and BP 124/84. What is the most appropriate nursing action?

Correct Answer is A

Explanation

A client is receiving gentamicin and vancomycin IV for urosepsis. Which diagnostic study result should the nurse report to the primary care practitioner?

Correct Answer is C

Explanation

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Question 92
A client is transferred to the Postanesthesia Care Unit (PACU) after surgery. The priority nursing intervention is: