A client has been admitted to the Post Anesthesia Care Unit (PACU) after a completing electroconvulsant therapy (ECT) treatment. Which action will the nurse perform first?

Assist the client from the stretcher to a wheelchair

Orient the client and offer reassurance

Encourage the client to drink some fluids

Assess vital signs and orient client to the PACU environment

Answer and Explanation

The Correct Answer is D

A. Assist the client from the stretcher to a wheelchair: Immediately after electroconvulsive therapy (ECT), the client is still recovering from anesthesia and may experience confusion, drowsiness, or muscle weakness. Transferring the client prematurely poses a fall risk and is not appropriate as the first action.

B. Orient the client and offer reassurance: While reorientation and reassurance are important aspects of post-ECT care, safety and physiological stability must be assessed first. This action should follow an initial assessment of vital signs and level of consciousness.

C. Encourage the client to drink some fluids: Offering fluids too soon after ECT is inappropriate because the client may have impaired swallowing reflexes from anesthesia or sedation. Ensuring the airway is clear and the client is fully alert must precede oral intake.

D. Assess vital signs and orient client to the PACU environment: The priority after any procedure involving anesthesia is to assess vital signs to ensure hemodynamic stability and monitor for complications. Once stable, the nurse can begin to orient the client, which is often needed after ECT due to temporary disorientation or memory lapses.

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Correct Answer is D

Explanation

A. Dopamine and 50% non-rebreather mask: Dopamine is a vasopressor used in hypotension or shock, an inotropic agent used to improve cardiac output, not typically first-line for anxiety or respiratory distress. A non-rebreather mask may provide high oxygen levels but can be overwhelming and exacerbate anxiety if not well tolerated.

B. Nesiritide IV infusion and digoxin PO: Nesiritide is a vasodilator which may reduce preload and afterload in heart failure, and digoxin is a positive inotrope that can improve contractility, but neither offers rapid relief for anxiety and dyspnea. These medications have slower onset and are not used primarily for symptom control in acute distress.

C. Diazepam IV push and metoprolol IV: While diazepam may reduce anxiety, it can depress respiration, which is dangerous in decompensated heart failure with potential pulmonary edema. Metoprolol reduces heart rate and contractility and must be used cautiously in acute settings.

D. Morphine IV and oxygen 2 liters via nasal cannula: Morphine reduces preload, anxiety, and the sensation of breathlessness, making it ideal in acute decompensated heart failure. Low-flow oxygen improves oxygenation without overwhelming the patient. This combination directly targets both physiologic and psychological distress.

A. The TEE evaluates if emboli are present if cardioversion is required B. The study will use electric current to stop the abnormal conduction pathway C. A TEE will help restore the client's underlying baseline normal rhythm, D. A TEE is required prior to implantable defibrillator placement in clients with atrial fibrillation

Correct Answer is A

Explanation

A. The TEE evaluates if emboli are present if cardioversion is required: A transesophageal echocardiogram (TEE) provides detailed imaging of the heart’s chambers, particularly the left atrium and left atrial appendage, where clots often form in atrial fibrillation. It is used to rule out thrombi before cardioversion to reduce the risk of stroke during the procedure.

B. The study will use electric current to stop the abnormal conduction pathway: This describes electrical cardioversion, not TEE. TEE is a diagnostic imaging procedure and does not involve the delivery of electrical currents to modify the heart's rhythm or conduction.

C. A TEE will help restore the client's underlying baseline normal rhythm: TEE does not treat arrhythmias. Its role is diagnostic—to visualize cardiac structures, not to restore normal rhythm. Cardioversion or pharmacologic agents are required to correct atrial fibrillation.

D. A TEE is required prior to implantable defibrillator placement in clients with atrial fibrillation: TEE is not routinely required before implantable cardioverter-defibrillator (ICD) placement. ICD decisions are usually based on ejection fraction, rhythm stability, and risk of sudden cardiac arrest, not the presence or absence of atrial thrombi.

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WBC	8.5
Hemoglobin	17g/dL
Hematocrit	54%
BUN	28mg/dL
Creatinine	1.1 mg/dL
Potassium	4.9 mEq/L

Potassium 2.8 mEq/L
Sodium 133 mEq/L
Chloride 90 mEq/L
Glucose 200 mg/dl
Magnesium 2.5 mg/dL
Calcium 8.0 mg/dL

A client has been admitted to the Post Anesthesia Care Unit (PACU) after a completing electroconvulsant therapy (ECT) treatment. Which action will the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with acute decompensated heart failure. The client is increasingly anxious and restless. The nurse should plan to implement which prescribed orders to assist in relieving these symptoms?

Correct Answer is D

Explanation

A client is admitted with uncontrolled atrial fibrillation with a rate between 120's-130's. IV heparin therapy is prescribed. In addition, the nurse prepares the client for a transesophageal echocardiogram (TEE). What does the nurse understand about this diagnostic study?

Correct Answer is A

Explanation

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