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 A
Explanation
A. Helping the client identify anxiety triggers is a crucial step in managing chronic anxiety. This allows the client to develop coping strategies and minimize stressors.
B. Repressing feelings of anxiety is not a healthy coping mechanism. Acknowledging and addressing anxiety through appropriate strategies is essential.
C. While contacting a counselor is beneficial, weekly contact is not typically needed for chronic anxiety management unless specified by the care plan.
D. It is unrealistic to eliminate all stress and anxiety. The goal is to manage and cope with these feelings, not to eliminate them completely.
Correct Answer is A
Explanation
A. Walking with the nurse in the courtyard provides a simple, safe, and structured activity that promotes physical exercise and reduces excess energy in a way that is appropriate for someone in a manic state. This also gives the nurse an opportunity to observe the client's behavior and provide supervision.
B. Watching a video with a group might not engage the client sufficiently and could be too passive for someone experiencing mania who might need a more stimulating activity.
C. Participating in a basketball game could be too physically demanding and might escalate the client's manic behavior, especially if they have high energy or impulsivity.
D. Joining a group discussion about a local election may not be stimulating enough for the client in a manic state, as it requires focus and attention that might be difficult for the client to maintain during acute mania.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.