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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. Assist the client in developing a structured schedule for activities of daily living B. Provide education about the irrationality of the behavior C. Collaborate with the client to set realistic goals for behavior change D. Encourage the client to resist the urge to rearrange items

Correct Answer is C

Explanation

A. A structured schedule may help with overall daily functioning, but it does not specifically address the compulsive behavior.

B. Educating the client about the irrationality of the behavior is unlikely to reduce the compulsions, as this is a hallmark of OCD, where the individual is often unable to control the urges despite understanding their irrationality.

C. Collaborating with the client to set realistic, gradual goals for changing the compulsive behavior is key in treating OCD. This approach allows the client to have input into their treatment plan and promotes realistic, achievable progress.

D. Encouraging the client to resist the urge to rearrange items without providing a structured approach may lead to increased anxiety and frustration. Gradual exposure and behavior modification are more effective.

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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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Naxlex Comprehensive Predictor Exams

A client with PTSD experiences exaggerated startle response. The client is paranoid and hypervigilant. Which nursing intervention is most appropriate?

Correct Answer is C

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A 35-year-old client with OCD spends several hours each day arranging and rearranging household items in a specific order. The client becomes extremely distressed if the items are not arranged correctly. Which nursing intervention is most appropriate?

Correct Answer is C

Explanation

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