The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

Blood pressure 110/70

heart rate 86

Hypoactive bowel sounds

Increased restlessness

Negative Homan's sign

Answer and Explanation

Correct Answer : D

a. Blood pressure 110/70: This is within normal range for many individuals and is not immediately concerning in the post-operative context.
b. heart rate 86: This is a normal heart rate for most individuals and is not concerning post-operatively.
c. Hypoactive bowel sounds: Hypoactive bowel sounds are common post-operatively due to anesthesia and are not immediately concerning.
d. Increased restlessness Increased restlessness can be a sign of pain, anxiety, hypoxia, or other complications and should be addressed promptly.
e. Negative Homan's sign: A negative Homan’s sign indicates no apparent deep vein thrombosis and is a positive finding.

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Correct Answer is C

Explanation

a. Is pathological and warrants postponing the test: Not necessarily true. Mild anxiety is a normal human response to stressful situations. Postponing the test might reinforce avoidance behaviors.
b. May be transferred to classmates and result in test anxiety: While anxiety can be contagious in some situations, the nurse should focus on calming techniques for the individual experiencing it, not assuming it will spread.
c. is conducive to concentration and problem solving (Correct): Mild anxiety, also known as arousal, can heighten focus and alertness. This can be beneficial for tasks that require concentration, like tests. In some cases, it can improve cognitive function
d. Will interfere with cognitive ability: Extreme anxiety can be debilitating, but mild anxiety can actually enhance focus and performance in some situations.

A. Listen to the breath sounds in all lung fields B. Document the amount of output on the I & O sheet C. Check the abdominal dressing for bleeding D. Increase the IV fluid flow rate if the blood pressure is low

Correct Answer is B

Explanation

a. Listen to the breath sounds in all lung fields: Assessing breath sounds is a more complex skill requiring a registered nurse's (RN) assessment.
b. Document the amount of output on the I & O sheet: Documenting intake and output (I&O) is a basic nursing task suitable for unlicensed nursing assistants (UNAs) under supervision.
c. Check the abdominal dressing for bleeding: Checking for bleeding requires a nurse's assessment due to the potential for complications.
d. Increase the IV fluid flow rate if the blood pressure is low: Adjusting IV fluids is a critical intervention requiring an RN's assessment and order.

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The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

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Naxlex Comprehensive Predictor Exams

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