The nurse is performing an ongoing assessment on a client admitted to the post-anesthesia care unit at 1655 following abdominal surgery. The nurse documents vital signs every five minutes, as noted in the Vital Signs Record. After reviewing the vital sign trends and notifying the provider, the nurse should anticipate administering what medication?

Midazolam (Versed)

Naloxone (Narcan)

Atropine (Atropen)

Dantrolene (Dantrium)

The correct answer is B.

Answer and Explanation

The Correct Answer is B

A. Midazolam (Versed): This is a benzodiazepine used for sedation. It is not typically used in the post-anesthesia care unit unless there is a need for additional sedation or anxiolysis, which is not indicated based on the scenario.
B. Naloxone (Narcan): This is the correct choice. Naloxone is used to reverse opioid-induced respiratory depression. If the vital signs indicate respiratory depression or decreased oxygen saturation potentially due to opioid medications used during surgery, naloxone would be administered.
C. Atropine (Atropen): This medication is used to treat bradycardia (slow heart rate) and is not typically indicated based on vital signs trends without specific symptoms.
D. Dantrolene (Dantrium): This medication is used to treat malignant hyperthermia, a rare but serious condition often triggered by certain anesthetics. It would be indicated if there were signs of this condition, such as a high fever and muscle rigidity, which is not mentioned in the scenario.

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Correct Answer is C

Explanation

A. A 58-year-old client who uses antacids every day: Antacids primarily affect gastric acid levels and are not typically associated with respiratory acidosis. They might affect metabolic balance but not respiratory acidosis.
B. A 48-year-old client with an anxiety disorder: Anxiety disorders are more commonly associated with respiratory alkalosis due to hyperventilation, not respiratory acidosis.
C. A 68-year-old client with chronic lung disease: This is the correct choice because chronic lung diseases, such as chronic obstructive pulmonary disease (COPD), often impair CO2 elimination, leading to respiratory acidosis due to CO2 retention.
D. A 28-year-old client with salicylate intoxication: Salicylate intoxication is often associated with metabolic acidosis, and initially, it can cause respiratory alkalosis due to hyperventilation, rather than respiratory acidosis.

A. Poorly controlled pain, moves all extremities, reports continued nausea B. 2-hour total urinary output of 30 mL, pulse oximetry 94% on 3L oxygen, turning from side to side C. Afebrile, adventitious breath sounds, responds to painful stimuli D. SaO2 of 95%, vital signs stable for last 30 minutes, active gag reflex

Correct Answer is D

Explanation

A. Poorly controlled pain, moves all extremities, reports continued nausea: Poorly controlled pain and nausea are not ideal for discharge, as they indicate the patient might need further monitoring and management.
B. 2-hour total urinary output of 30 mL, pulse oximetry 94% on 3L oxygen, turning from side to side: Low urinary output and low oxygen saturation indicate potential complications that require further assessment and treatment.
C. Afebrile, adventitious breath sounds, responds to painful stimuli: Responding to painful stimuli and adventitious breath sounds suggest the patient may still be experiencing complications and is not ready for discharge.
D. SaO2 of 95%, vital signs stable for last 30 minutes, active gag reflex: This response indicates stable oxygen saturation, stable vital signs, and an active gag reflex, suggesting the patient is ready for discharge from the PACU.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care for several clients at risk for acid-base imbalance. Which client has the greatest risk for respiratory acidosis?

Correct Answer is C

Explanation

Which client response best supports the decision to discharge the client from the Post-Anesthesia Care Unit?

Correct Answer is D

Explanation

The nurse working on a medical surgical unit is assigned four clients at the start of their shift. What client should be given the highest priority?

The nurse is taking a medication history of a client scheduled for surgery the next morning. Which medication requires the nurse to immediately notify the surgeon?

The client has received IV solution for three (3) days through a 20-gauge IV catheter placed in the left hand. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?

The nurse identifies that which of the following clients is at risk for developing metabolic acidosis? (Select All That Apply)

To promote effective coughing, deep breathing, and ambulation in the postoperative client, what nursing action is most important?

A physician orders regular insulin 10 units I.V. along with 50 ml of dextrose 50% for a client with acute renal failure newly admitted to the critical care unit. What electrolyte imbalance is this client most likely experiencing?

Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?

The nurse is rounding on a client who is 12 hours postoperative. Upon assessment, the client becomes tachycardic, hypotensive, and restless and complains of sudden chest pain. Which postoperative complication should the nurse conclude that the client most likely experienced?