A stable postoperative client is ready to leave the post-anesthesia care unit (PACU). Which nursing action is most important by the nurse on the medical-surgical unit?

Administer pain medication

Assess the client’s respiratory status

Check the surgical dressing

Monitor urine output

Answer and Explanation

The Correct Answer is B

Choice A reason: Administering pain medication is important for comfort but not the most critical action upon PACU transfer. Pain is typically managed in the PACU, and respiratory complications like atelectasis or hypoxia are life-threatening, making respiratory assessment the priority to ensure client stability.

Choice B reason: Assessing respiratory status is critical upon PACU transfer, as postoperative clients risk respiratory complications like atelectasis or airway obstruction from anesthesia. Ensuring adequate oxygenation and ventilation prevents hypoxia, making this the priority to ensure client safety and detect early signs of respiratory distress.

Choice C reason: Checking the surgical dressing assesses for bleeding or infection but is secondary to respiratory status. Wound complications are less immediately life-threatening than respiratory issues, which can cause rapid hypoxia, making dressing checks a lower priority upon transfer to the medical-surgical unit.

Choice D reason: Monitoring urine output assesses renal function and fluid status but is not the most urgent upon PACU transfer. Respiratory complications pose a greater immediate risk, as anesthesia and surgery impair lung function, making respiratory assessment the priority to prevent hypoxia-related complications.

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Correct Answer is B

Explanation

Choice A reason: Administering medications that promote fluid retention, like vasopressin, worsens hypervolemia by increasing water reabsorption, exacerbating edema and hypertension. This is contraindicated, as the goal is fluid removal, making this an incorrect intervention for managing excess fluid volume in hypervolemia.

Choice B reason: Administering diuretics is the priority in hypervolemia, promoting renal excretion of excess fluid, reducing edema, pulmonary congestion, and hypertension. Diuretics like furosemide correct fluid overload, preventing complications like heart failure exacerbation, making this the most critical intervention for immediate fluid management.

Choice C reason: Encouraging increased fluid intake worsens hypervolemia by adding to excess fluid, increasing pulmonary edema and heart failure risks. The goal is to remove fluid, not add it, making this inappropriate compared to diuretics, which directly address fluid overload in this condition.

Choice D reason: Monitoring daily weights tracks fluid status but is not an intervention. While useful for assessing treatment response, it does not reduce fluid volume like diuretics, which prevent complications, making weight monitoring a supportive, not primary, action in hypervolemia management.

A. Increased respiratory rate B. Clear lung sounds C. Brisk capillary refill D. Decreased pleuritic pain

Correct Answer is B

Explanation

Choice A reason: Increased respiratory rate suggests persistent respiratory distress or ineffective airway clearance in pneumonia, as the body compensates for hypoxia or hypercapnia. This indicates ongoing secretions or inflammation, not a therapeutic response, making it an incorrect indicator compared to clear lung sounds.

Choice B reason: Clear lung sounds indicate effective airway clearance in pneumonia, as treatments like antibiotics and chest physiotherapy reduce secretions and inflammation, allowing normal air movement. This reflects resolved airway obstruction and improved gas exchange, making it the best indicator of a therapeutic response to treatment.

Choice C reason: Brisk capillary refill reflects adequate peripheral perfusion but is unrelated to airway clearance in pneumonia. It does not indicate resolution of secretions or improved lung function, making it an irrelevant marker for evaluating treatment response compared to clear lung sounds, which directly assess airway patency.

Choice D reason: Decreased pleuritic pain suggests reduced pleural inflammation but does not confirm airway clearance. Pain reduction may occur without clearing secretions, the primary issue in pneumonia. Clear lung sounds better indicate successful treatment by demonstrating unobstructed airways and improved respiratory function.

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A stable postoperative client is ready to leave the post-anesthesia care unit (PACU). Which nursing action is most important by the nurse on the medical-surgical unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Explanation

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