Which client response best supports the decision to discharge the client from the Post-Anesthesia Care Unit?

Poorly controlled pain, moves all extremities, reports continued nausea

2-hour total urinary output of 30 mL, pulse oximetry 94% on 3L oxygen, turning from side to side

Afebrile, adventitious breath sounds, responds to painful stimuli

SaO2 of 95%, vital signs stable for last 30 minutes, active gag reflex

Answer and Explanation

The Correct Answer is D

A. Poorly controlled pain, moves all extremities, reports continued nausea: Poorly controlled pain and nausea are not ideal for discharge, as they indicate the patient might need further monitoring and management.
B. 2-hour total urinary output of 30 mL, pulse oximetry 94% on 3L oxygen, turning from side to side: Low urinary output and low oxygen saturation indicate potential complications that require further assessment and treatment.
C. Afebrile, adventitious breath sounds, responds to painful stimuli: Responding to painful stimuli and adventitious breath sounds suggest the patient may still be experiencing complications and is not ready for discharge.
D. SaO2 of 95%, vital signs stable for last 30 minutes, active gag reflex: This response indicates stable oxygen saturation, stable vital signs, and an active gag reflex, suggesting the patient is ready for discharge from the PACU.

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Correct Answer is C

Explanation

A. Imitation of the lining of the stomach: This is not a common complication related to calcium supplementation or fluid intake.
B. Mobilization of calcium from bones: Drinking fluids does not affect the mobilization of calcium from bones; this is more related to bone health and calcium metabolism.
C. Developing kidney stones: Adequate fluid intake helps prevent kidney stones, which can form when there is excess calcium in the urine. High calcium levels can lead to stone formation if not properly managed with sufficient hydration.
D. Developing muscle cramps: While calcium plays a role in muscle function, fluid intake primarily helps with kidney function and preventing stone formation rather than directly preventing muscle cramps.

A. Level of consciousness B. Condition of drains C. Appearance of the surgical dressing D. Stability of vital signs

Correct Answer is D

Explanation

A. Level of consciousness: While important, it follows the assessment of vital signs to ensure the client's overall stability.
B. Condition of drains: This is relevant but not as immediate as assessing the stability of vital signs.
C. Appearance of the surgical dressing: This is important but secondary to ensuring the client’s vital signs are stable.
D. Stability of vital signs: This is the most critical next assessment after ensuring a patent airway, as vital signs reflect the client's immediate physiological status and stability.

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Which client response best supports the decision to discharge the client from the Post-Anesthesia Care Unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education in a community setting to several clients taking daily calcium supplements and encourages them to drink 2,500 mL of fluid daily. The nurse explains that this intervention is important to prevent which complication?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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