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. A key outcome criterion for clients with anxiety disorder is the ability to demonstrate effective coping strategies, such as relaxation techniques or problem-solving, to manage anxiety.
B. Reduced hallucinations would be a goal for a client with a psychotic disorder, not an anxiety disorder.
C. Persistent avoidance behaviors would indicate that the client’s anxiety is not being effectively managed.
D. Feelings of tension and fatigue are common symptoms of anxiety and would not be considered an appropriate outcome for treatment.
Correct Answer is B
Explanation
A. Posttraumatic stress response involves reliving traumatic events, flashbacks, and hyperarousal, not specifically avoidance due to anxiety about leaving the home.
B. Agoraphobia is characterized by a fear of situations where escape might be difficult or help unavailable, leading to avoidance behavior such as being unable to leave home. It often co-occurs with panic disorder.
C. Generalized anxiety disorder involves excessive worry about multiple areas of life but not specific avoidance behaviors like agoraphobia.
D. Obsessive-compulsive disorder involves intrusive thoughts (obsessions) and repetitive behaviors (compulsions), but not the avoidance behavior characteristic of agoraphobia.
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