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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.)

Presence of cough

Absence of gag reflex

Respiratory rate of 6 breaths per minute

Urine output 90 mL/hour

Heart rate 70 beats per minute

Capillary refill less than 3 seconds

Answer and Explanation

Correct Answer : B,C

A. The presence of a cough is expected as a protective reflex and does not delay transfer.

B. The absence of a gag reflex increases the risk of aspiration, delaying safe transfer.

C. A respiratory rate of 6 breaths per minute indicates respiratory depression, which requires immediate intervention.

D. Urine output of 90 mL/hour is within the expected range and does not delay transfer.

E. A heart rate of 70 beats per minute is normal and not a contraindication for transfer.

F. Capillary refill less than 3 seconds is normal and does not delay the transfer.

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Correct Answer is D

Explanation

A. Isolating the client is not helpful and may increase anxiety, potentially worsening the compulsive behaviors.

B. Setting strict limits can lead to resistance and increased anxiety, making compulsive behaviors more difficult to manage.

C. Confronting the client about the senseless nature of their compulsions is not effective and may increase anxiety, making the behaviors more intense. Instead, it is important to provide support and understanding while working with the client to reduce the impact of OCD on daily functioning.

D. Clients with OCD often perform compulsive rituals to reduce anxiety. Planning time for rituals allows the nurse to balance the need to manage the behavior with the need to provide structure and care.

A. Administer the morning dose of lithium. B. Check the client's medication record to assess whether the client has been refusing her lithium. C. Prepare for gastric lavage due to an extremely elevated lithium level. D. Hold the medication and assess for early manifestations of toxicity.

Correct Answer is A

Explanation

A. A lithium level of 1.0 mEq/L is within the therapeutic range (0.6 to 1.2 mEq/L). The nurse should administer the morning dose of lithium as prescribed.

B. While it is important to monitor for medication adherence, there is no indication from the current lithium level that this client is refusing the medication.

C. Gastric lavage is unnecessary, as the lithium level is not elevated enough to warrant this extreme intervention.

D. Early signs of lithium toxicity typically occur with levels above 1.5 mEq/L. Since the level is 1.0 mEq/L, the nurse should proceed with administering the medication.

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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.)

Nursing Test Bank

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