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 A

Explanation

A. Clients with ICDs should avoid strong electromagnetic fields, which can interfere with the device’s function. This is crucial for safety.

B. Discontinuing antidysrhythmic medication is not recommended unless instructed by the healthcare provider, as it could increase the risk of arrhythmias.

C. Strenuous exercise may be too strenuous for someone with an ICD and could increase the risk of arrhythmias or lead to ICD activation.

D. A snug-fitting shirt is generally not recommended because it may place pressure on the ICD site and cause discomfort.

A. Hydration and urine output are maintained by bladder irrigation. B. Bladder irrigation prevents obstruction of the catheter after surgery. C. Bladder irrigation decreases the risk of postoperative bleeding. D. Antibiotics are infused continuously through the bladder irrigation.

Correct Answer is B

Explanation

A. Hydration and urine output are maintained through IV fluids and kidney function, not bladder irrigation.

B. Continuous bladder irrigation prevents catheter obstruction by flushing out blood clots or debris after TURP surgery. This is the primary purpose of the procedure.

C. While bladder irrigation may help reduce bleeding indirectly by maintaining flow, it is not its main purpose.

D. Antibiotics are not typically administered via bladder irrigation; systemic routes are preferred for infection control.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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