A client has just been admitted to the Post Anesthesia Care Unit after electroconvulsive therapy (ECT). Which intervention will the nurse perform first?

Orient the client and offer reassurance

Encourage the client to drink some fluids

Orient the client and monitor vital signs

Assist the client from the stretcher to a wheelchair

Answer and Explanation

The Correct Answer is C

C. After ECT, the client may be disoriented, confused, or drowsy due to the effects of anesthesia and the procedure itself. Orienting the client to their surroundings and situation helps promote their safety and comfort. Monitoring vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is crucial to assess the client's immediate post-procedural status and detect any complications.
A. Offering reassurance can help alleviate any anxiety or confusion the client may experience. However, while this intervention is important, it may not be the first priority immediately upon admission to the Post Anesthesia Care Unit (PACU).
B. Hydration is important after any medical procedure, including ECT. However, immediately after ECT, the client may still be recovering from anesthesia and may not be fully alert or able to safely drink fluids.
D. Assisting the client with mobility is important but it may not be the first intervention performed in the PACU after ECT. The priority immediately upon admission to the PACU is to ensure the client's safety.

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Correct Answer is C

Explanation

C. Sodium intake can influence lithium excretion and affect serum lithium levels. Maintaining a consistent and adequate sodium intake is important for stabilizing serum lithium levels and optimizing the medication's therapeutic effects.
A. Patients should have their serum lithium levels checked regularly, typically every 3 months, not just every 6 months as suggested.
B. Clients should never adjust their lithium dose without consulting their healthcare provider. Lithium dosage adjustments should be made only under the guidance and supervision of a healthcare professional based on the client's clinical response, serum lithium levels, and overall treatment plan.
D. Adequate hydration is essential for overall health and well-being, and dehydration can increase the risk of lithium toxicity.

A. orient to reality. B. identify social supports. C. replace fluids. D. apply restraints.

Correct Answer is C

Explanation

C. Alcohol withdrawal can lead to dehydration due to symptoms such as vomiting, diarrhea, and increased urination. Replacing fluids is important to prevent dehydration and maintain electrolyte balance.
A. Orienting the individual to reality involves helping them understand their current situation and surroundings. While this is an important aspect of nursing care, it may not be the highest priority during the initial phase of alcohol withdrawal.
B. Social support is vital for individuals undergoing alcohol withdrawal, as it can provide emotional reassurance and assistance during a challenging time. However, during the initial phase of withdrawal, the highest priority is typically addressing immediate physiological needs.
D. Restraints should only be used as a last resort and in situations where there is an imminent risk of harm to the individual or others.

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A client has just been admitted to the Post Anesthesia Care Unit after electroconvulsive therapy (ECT). Which intervention will the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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