The post anesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first?

Client with a blood pressure of 90/50 mm Hg.

Client with a temperature of 96° F (35.6° C).

Client with a pulse of 118 beats/min.

Client with a respiratory rate of 6 breaths/min.

Answer and Explanation

The Correct Answer is D

A. A blood pressure of 90/50 mm Hg is concerning, but it is less urgent than severe respiratory depression. The nurse should still assess this client promptly.

B. A temperature of 96° F (35.6° C) is mildly low and should be addressed, but it is not as critical as a severely low respiratory rate.

C. A pulse of 118 beats/min is elevated and may require monitoring, but it does not pose as immediate a threat as respiratory depression.

D. A respiratory rate of 6 breaths/min is critically low, which may indicate respiratory depression, particularly after anesthesia. Immediate assessment and intervention are needed to ensure adequate oxygenation and ventilation.

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Correct Answer is B

Explanation

A. A small, mobile, rubbery lump is often benign, such as a fibroadenoma.

B. A nontender, fixed breast nodule is concerning for malignancy, and further evaluation is necessary, such as imaging or biopsy.

C. Tender, bilateral nodules are commonly seen in benign conditions like fibrocystic breast changes, especially related to the menstrual cycle.

D. A lump that changes in size before menstruation is also typical of benign conditions like fibrocystic changes.

A. "I have experienced blurred vision on several occasions." B. "I must stop halfway up the stairs to catch my breath." C. "I have been drinking more water than usual." D. "I am awakened by the need to urinate at night."

Correct Answer is B

Explanation

A. Blurred vision is not a typical symptom of left-sided heart failure.

B. Difficulty breathing while performing activities, such as climbing stairs, is a classic symptom of left-sided heart failure due to pulmonary congestion.

C. Increased water intake is not directly indicative of left-sided heart failure.

D. Nocturia can occur in heart failure, but it is less specific than dyspnea on exertion.

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The post anesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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