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 C
Explanation
A. Persistent low-grade depression without hypomania is not typical of bipolar II disorder, as hypomanic episodes are a key feature of the disorder.
B. Psychosis is more common during full manic episodes, typically seen in bipolar I disorder, not bipolar II.
C. Bipolar II disorder is characterized by hypomanic episodes that alternate with major depressive episodes. Hypomania is a less severe form of mania, and individuals with bipolar II do not experience full manic episodes as in bipolar I.
D. Severe manic episodes are characteristic of bipolar I disorder, not bipolar II, which involves hypomanic episodes instead.
Correct Answer is B
Explanation
A. Chills are not a common symptom of moderate anxiety; they are more likely to occur with fever or cold exposure.
B. Anxiety often leads to physical symptoms such as urinary frequency due to increased sympathetic nervous system activity.
C. Rapid speech can occur with anxiety, but it is more commonly seen in severe anxiety, not moderate anxiety.
D. A distorted perceptual field is more typical of severe anxiety or panic attacks, not moderate anxiety.
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