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","D","E"]
Explanation
A. Sleeping for long periods of time would typically indicate depression, not mania.
B. Dressing in black or grey clothing is not typically associated with mania; this could be a symptom of depression, which tends to cause social withdrawal and lack of energy.
C. Rapid, continuous speech (pressured speech) is a common symptom of mania, where the individual is unable to control the flow of conversation.
D. Spending large sums of money without regard for the consequences is a typical behavior during manic episodes, often linked to impulsivity and poor judgment.
E. Flirtatious behavior can indicate impulsivity, another characteristic of mania, where the person may act inappropriately or without regard for social boundaries.
Correct Answer is D
Explanation
A. Naloxone is an opioid antagonist used to reverse opioid overdoses, not benzodiazepines.
B. Diphenhydramine is an antihistamine, not an antagonist for benzodiazepines.
C. Protamine is used to reverse the effects of heparin (an anticoagulant), not benzodiazepines.
D. Flumazenil is a benzodiazepine antagonist used to reverse the effects of benzodiazepine overdose or sedation.
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