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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. While support groups may be helpful, the immediate intervention for a client experiencing heightened anxiety and hypervigilance is to provide structure and safety.

B. Mindfulness meditation may be beneficial in the long term, but it is not the first intervention in an acute phase where anxiety and hypervigilance are prominent.

C. A structured environment with predictable routines and consistent staff can help clients with PTSD feel more secure and reduce feelings of anxiety, hypervigilance, and paranoia. Predictability and structure are key interventions for clients with PTSD.

D. Administering a PRN sedative medication should be a secondary intervention after providing a supportive and safe environment. Medications may be used as part of treatment, but they do not address the underlying anxiety and hypervigilance as effectively as a structured environment.

A. The client's behavior has become impulsive in the past few weeks. B. The client identifies with problems expressed by other clients. C. The client states she wants to go home to be with her children and partner. D. The client has begun playing basketball with several other clients during the past month.

Correct Answer is A

Explanation

A. Impulsivity, a hallmark of mania, can increase the risk of suicidal behavior, particularly if the client makes rash decisions without regard for consequences.

B. Identifying with problems expressed by others does not necessarily indicate suicidal thoughts, but rather may show empathy or a desire for connection.

C. Wanting to go home may indicate longing for normalcy, but by itself, it does not suggest imminent risk for suicide.

D. Playing basketball can indicate engagement with others and an improvement in mood or functioning, rather than an increased suicide risk.

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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.)

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