The nurse has received hand-off report on a client that is being admitted to the unit from the post-anesthesia care unit (PACU). Which is the priority action for the nurse to take when the client arrives to the unit?
Orient the client to the room
Assure the call light is within reach
Call the provider for orders
Assess vital signs
The Correct Answer is D
A. Orient the client to the room: Orientation is important for patient comfort and safety, especially after anesthesia when confusion may be present. However, it is not the priority action immediately upon arrival, as physiological stability must be assessed first before addressing environmental familiarity.
B. Assure the call light is within reach: Ensuring the call light is accessible supports patient safety and autonomy, particularly in preventing falls or unmet needs. Despite its importance, this intervention follows confirmation of the patient’s immediate physiological status.
C. Call the provider for orders: Orders are typically already established prior to transfer from the PACU. Contacting the provider without first assessing the patient may delay identification of urgent postoperative complications such as airway compromise, hemorrhage, or hemodynamic instability.
D. Assess vital signs: The immediate priority is to evaluate airway, breathing, circulation, and overall stability following anesthesia. Postoperative clients are at risk for complications such as respiratory depression, hypotension, and bleeding. Assessing vital signs allows early detection of deterioration and guides urgent interventions if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Respiratory alkalosis: The pH of 7.68 indicates alkalemia, and the PaCO2 is decreased at 30 mmHg, demonstrating a primary respiratory disturbance. The low PaCO2 is consistent with hyperventilation, which causes excessive CO2 exhalation, leading to alkalosis. Although HCO3- is slightly decreased, this likely represents a compensatory metabolic response rather than a primary metabolic disorder, aligning with respiratory alkalosis as the principal abnormality.
B. Respiratory acidosis: Respiratory acidosis is characterized by acidemia (pH <7.35) and elevated PaCO2 (>45 mmHg) due to hypoventilation or impaired gas exchange. In this ABG, the pH is alkalotic and PaCO2 is decreased, which is opposite the pattern seen in respiratory acidosis.
C. Normal ABG results: Normal ABG parameters include pH 7.35–7.45, PaCO2 35–45 mmHg, HCO3- 22–28 mEq/L, and PaO2 80–100 mmHg. This patient’s pH is significantly elevated, PaCO2 is below normal, HCO3- is reduced, and base excess is abnormal, all indicating a pathophysiologic process rather than a normal state.
D. Metabolic acidosis: Metabolic acidosis involves low pH and decreased HCO3- as the primary disturbance. Although HCO3- is reduced at 16.2 mEq/L, the elevated pH and decreased PaCO2 indicate alkalemia with a primary respiratory origin, making metabolic acidosis an incorrect interpretation.
Correct Answer is B
Explanation
A. Administer potassium chloride IV push: Administering potassium as an IV push is extremely dangerous because rapid infusion can cause life-threatening cardiac arrhythmias, including ventricular fibrillation or cardiac arrest. Potassium replacement must be administered slowly and diluted according to protocol, not as a push.
B. Monitor cardiac rhythm: Hypokalemia (K⁺ 3.1 mEq/L) increases the risk of cardiac dysrhythmias, including premature ventricular contractions, atrial fibrillation, and ventricular tachycardia. Continuous cardiac monitoring allows early detection of arrhythmias and guides safe interventions, making this the priority action.
C. Administer a diuretic: Administering a diuretic would further lower potassium levels, worsening hypokalemia and increasing the risk of dysrhythmias. This intervention is contraindicated in this situation and could be harmful.
D. Range of motion exercises: While maintaining mobility is generally beneficial, range of motion exercises do not address the immediate risk of hypokalemia-induced cardiac complications. Cardiac monitoring and safe potassium replacement take priority over non-urgent mobility activities.
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