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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. Hormonal therapy may be used for PMDD but is not a distinguishing factor from PMS.

B. PMDD involves both mood and physical symptoms, unlike PMS, which primarily involves physical symptoms.

C. PMDD symptoms may persist through the beginning of menstruation, unlike PMS, which typically resolves with the onset of the period.

D. Premenstrual dysphoric disorder (PMDD) is a more severe form of premenstrual syndrome (PMS) characterized by mood disturbances, irritability, and functional impairment that significantly affect a person’s ability to function in daily life.

A. Potassium 4.2 mEq/L B. Sodium 136 mEq/L C. Calcium 9.0 mg/dL D. Creatinine 2.1 mg/dL

Correct Answer is D

Explanation

A. Potassium 4.2 mEq/L is within the normal range (3.5–5.0 mEq/L).

B. Sodium 136 mEq/L is slightly low but does not warrant withholding lithium. However, sodium levels should be monitored regularly as low sodium increases the risk of lithium toxicity.

C. A calcium level of 9.0 mg/dL is within the normal range (8.5–10.2 mg/dL).

D. An elevated creatinine level (2.1 mg/dL) indicates possible renal dysfunction, which is a concern for lithium use. Lithium is excreted by the kidneys, and impaired renal function increases the risk of lithium toxicity.

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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.)

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Naxlex Comprehensive Predictor Exams

A client with Premenstrual dysphoric disorder (PMDD) asks how her condition differs from premenstrual syndrome (PMS). What is the nurse's best response?

Correct Answer is D

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A patient diagnosed with bipolar disorder is prescribed lithium carbonate. Which laboratory result should prompt the nurse to hold the medication and notify the healthcare provider?

Correct Answer is D

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