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 E

Explanation

A. contact the prescriber to decrease the rate of the D51/2NS during the blood transfusion: There's no need to alter the rate of maintenance fluids unless there's a fluid volume concern. Additionally, decreasing the rate would not address the need for a dedicated blood transfusion line if another lumen is available.

B. stop the D51/2NS, check the client's vitals & notify the prescriber: Stopping necessary fluids without cause may compromise fluid balance. Unless there's a compatibility issue or no other lumen, stopping the infusion is not the safest or most efficient action.

C. Fluids cannot be given through a CVC: Central venous catheters are routinely used for administering fluids, medications, and blood products, especially in critical care settings.

D. Insert a 22 gauge peripheral IV to administer the transfusion: While blood can be given through a peripheral IV, using an existing central venous catheter is safer and more efficient, especially when multiple lumens are available. Inserting a new IV unnecessarily increases infection and complication risks.

E. transfuse the unit of packed red blood cells through a separate lumen of the CVC: This is the safest and most appropriate action. Triple-lumen CVCs allow for simultaneous infusions through separate channels without mixing. Blood should be transfused through a dedicated lumen to avoid incompatibility or dilution by other fluids.

A. Dehydration B. Infection C. Renal insufficiency D. internal bleeding

Correct Answer is A

Explanation

A. Dehydration: The elevated hemoglobin (17 g/dL) and hematocrit (54%), along with an increased BUN (28 mg/dL) and normal creatinine, suggest hemoconcentration, a key indicator of dehydration. Small bowel obstruction often leads to fluid loss through vomiting and third spacing into the bowel, contributing to this condition.

B. Infection: The WBC count is normal at 8.5, which does not support an active infection. Infections typically result in leukocytosis (WBC >10.5), especially in acute abdominal conditions.

C. Renal insufficiency: Although BUN is elevated, creatinine remains normal (1.1 mg/dL). This pattern, particularly with hemoconcentration, supports pre-renal azotemia due to dehydration, not intrinsic renal insufficiency.

D. Internal bleeding: Internal bleeding typically causes a decrease in hemoglobin and hematocrit due to blood loss. The elevated values in this case rule out active bleeding and instead indicate fluid volume deficit.

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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

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

A client has a triple lumen subclavian central venous catheter (CVC) with D51/2NS infusing through one lumen (port) at 75 mL per hour. The nurse has an order to transfuse one unit of packed red blood cells (PRBCs). The nurse's safest action is to:

Correct Answer is E

Explanation

Correct Answer is A

Explanation

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