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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?

Continue monitoring the vitals

inform the surgeon about the increase in temperature

increase intravenous fluid rates

inform the surgeon about the decrease in blood pressure

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is A

Explanation

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.

A. Cover the bowel with wet sterile gauze B. Assist the client into a low-Fowler's position with knees flexed C. Assist the client into a side-lying position with knees flexed D. Retrieve the crash cart from the nursing station E. Call for assistance F. Measure the client's inspiratory volume via incentive spirometer

Correct Answer is ["A","B","E"]

Explanation

A: Covering the bowel with sterile gauze moistened with saline protects the exposed tissue and prevents it from drying out.

B: A low-Fowler's position with knees flexed reduces strain on the abdomen and minimizes further protrusion.

C: A side-lying position does not relieve strain on the abdominal incision as effectively as a low-Fowler’s position.

D: Retrieving the crash cart is unnecessary unless there is evidence of impending cardiopulmonary arrest.

E: Calling for assistance is essential to notify the surgical or medical team promptly.

F: Measuring inspiratory volume is irrelevant in this scenario and delays appropriate intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

The nurse is caring for a client in the immediate post-operative period. On assessment, the nurse notes the client's bowels are protruding from the abdominal incision. Which intervention(s) by the nurse are most appropriate at this time? (Select All That Apply]

Correct Answer is ["A","B","E"]

Explanation

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?

A nurse is caring for a client receiving Propofol for sedation during a medical procedure. Which assessment finding should the nurse prioritize when monitoring the client's response to Propofol?

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What type of procedural information should be given to a client in preparation for ambulatory surgery? (Select All that Apply)

A nurse is caring for a client who is scheduled for a surgical procedure. 3 Exhibits The nurse is reviewing the client's electronic medical record. Which of the following findings places the client at risk for a surgical complication? Select all that apply.

The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)

A nurse is working in a preoperative unit. Which task is most appropriate to be delegated to unlicensed assistive personnel (UAP)?

A nurse is caring for a client experiencing malignant hyperthermia. Which intervention(s) is/are appropriate for this client? [Select All That Apply]

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?