A nurse is caring for several clients in the post-operative unit. Which client should the nurse see first?

Client with oxygen saturation of 8996

Client with a blood pressure of 8.8/58 mm Hg

Client with temperature of 102 F

Client with respiratory rate of 12 breaths/min

Answer and Explanation

The Correct Answer is A

A. An oxygen saturation of 89% indicates hypoxemia, which poses an immediate threat to oxygenation and requires urgent intervention.

B. Hypotension is concerning but less critical than hypoxemia in this scenario.

C. A fever of 102°F requires monitoring and management but is not an immediate life threat.

D. A respiratory rate of 12 breaths/min is normal for an adult and does not require immediate action.

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Correct Answer is A

Explanation

A. The changes in vital signs are within expected ranges post-procedure, so continued monitoring is appropriate.

B. A temperature increase to 99°F is not significant and does not require immediate reporting.

C. No signs of hypovolemia or dehydration warrant increasing IV fluids.

D. A blood pressure decrease to 112/72 mm Hg is minimal and not concerning.

A. Discuss alternatives to the procedure. B. Inform the provider that the client is withdrawing consent C. Explain why this procedure is necessary. D. Remind the client the consent form has already has been signed.

Correct Answer is B

Explanation

A. While discussing alternatives may be beneficial later, it is not the priority action when consent is withdrawn.

B. Informing the provider ensures the client’s right to withdraw consent is respected and initiates appropriate communication.

C. Explaining why the procedure is necessary may feel coercive and does not prioritize the client’s autonomy.

D. Reminding the client about the signed consent form undermines their right to change their decision.

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A nurse is caring for several clients in the post-operative unit. Which client should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits A client is brought to post anesthesia care unit (PACU) after an invasive procedure. Based on the two sets of vital signs in the chart tab, which action is most appropriate by the nurse?

Correct Answer is A

Explanation

A nurse is caring for a client who has provided informed consent in preparation for a procedure. The client states, "I have decided not to have the procedure." Which action should the nurse take?

Correct Answer is B

Explanation

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