A client is being transferred to the medical-surgical unit from the PACU after receiving general anesthesia for a procedure. Which of the following actions is the priority for the nurse when the client arrives on the unit?

Assess airway patency

Check the dressing to assess bleeding.

Check tubes or drains for patency.

Assess all vital signs.

Answer and Explanation

The Correct Answer is A

A. Assess airway patency: Ensuring the airway is patent is the highest priority because compromised airway patency can lead to life-threatening respiratory complications. This is the first step in the ABCs (Airway, Breathing, Circulation) of emergency and postoperative care.
B. Check the dressing to assess bleeding: While assessing the dressing for bleeding is important, it is secondary to ensuring the client has a patent airway. Uncontrolled bleeding can be addressed after confirming the client can breathe adequately.
C. Check tubes or drains for patency: Checking tubes and drains for patency is also important, but it should be done after ensuring the client's airway is secure. This step is essential for preventing complications but is not as immediately critical as airway assessment.
D. Assess all vital signs: Assessing vital signs is crucial, but it follows after ensuring airway patency. Vital signs provide comprehensive information about the client's status, but an obstructed airway must be addressed first to ensure effective breathing and oxygenation.

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Correct Answer is B

Explanation

A. 5-hour urine output total of 300 mL: This urine output is low, but it may not immediately indicate a serious issue without additional context. However, monitoring for adequate urine output is important.
B. Serum potassium level of 3.0 mEq/L: This is the correct choice. A serum potassium level of 3.0 mEq/L indicates hypokalemia, a serious side effect of furosemide, which can lead to cardiac arrhythmias and requires immediate intervention.
C. Current blood pressure of 141/80 mm Hg: Although the blood pressure is still elevated, it is not as urgent as correcting hypokalemia. The medication’s effectiveness should be monitored, but it is not an immediate concern.
D. Serum glucose level of 135 mg/dL: This level is slightly elevated but not critically high, and it does not require immediate action related to furosemide use.

A. Muscle cramps B. Bradycardia C. Concentrated urine D. Tachycardia E. Increased thirst

Correct Answer is ["A","C","D","E"]

Explanation

A. Muscle cramps: Muscle cramps can occur due to electrolyte imbalances, such as low potassium, which are common in states of dehydration and fluid imbalance.
B. Bradycardia: Bradycardia is not typically associated with dehydration or fluid imbalance. Dehydration usually causes an increase in heart rate (tachycardia) as the body tries to maintain adequate circulation.
C. Concentrated urine: Concentrated urine is a common sign of dehydration as the kidneys conserve water, leading to reduced urine output and higher urine concentration.
D. Tachycardia: Tachycardia is a compensatory mechanism in response to decreased fluid volume, as the heart pumps faster to maintain adequate blood flow and blood pressure.
E. Increased thirst: Increased thirst is a natural response to dehydration as the body signals the need for more fluid intake to correct the fluid imbalance.

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A client is being transferred to the medical-surgical unit from the PACU after receiving general anesthesia for a procedure. Which of the following actions is the priority for the nurse when the client arrives on the unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A hospitalized client is receiving IV furosemide (Lasix) to treat stage 2 hypertension. Which assessment finding related to the medication requires prompt collaboration with the health care provider?

Correct Answer is B

Explanation

Correct Answer is ["A","C","D","E"]

Explanation

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