The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)
Presence of cough
Absence of gag reflex
Respiratory rate of 6 breaths per minute
Urine output 90 mL/hour
Heart rate 70 beats per minute
Capillary refill less than 3 seconds
Correct Answer : B,C
A. The presence of a cough is expected as a protective reflex and does not delay transfer.
B. The absence of a gag reflex increases the risk of aspiration, delaying safe transfer.
C. A respiratory rate of 6 breaths per minute indicates respiratory depression, which requires immediate intervention.
D. Urine output of 90 mL/hour is within the expected range and does not delay transfer.
E. A heart rate of 70 beats per minute is normal and not a contraindication for transfer.
F. Capillary refill less than 3 seconds is normal and does not delay the transfer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Resting in bed may be helpful later, but it does not provide the immediate reassurance and support needed during a panic attack.
B. Remaining with the client provides reassurance, safety, and emotional support during a panic attack, which is essential for de-escalation.
C. Having the client join a therapy group during a panic attack would be overwhelming and inappropriate.
D. Administering a sedative may be considered later but should not be the first intervention, as verbal support and reassurance are the priority during a panic attack.
Correct Answer is C
Explanation
A. Hearing voices could indicate psychosis, which is not specifically linked to acute mania in bipolar disorder. Mania may involve delusions or grandiosity but not auditory hallucinations.
B. Dressing in all black is not specific to acute mania and could be related to personal style or another mood state.
C. Disorganized speech is a hallmark symptom of acute mania in bipolar disorder. The individual may exhibit flight of ideas, rapid speech, or incoherent thoughts.
D. Weight gain is more commonly associated with depression or medication side effects, not acute mania.
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