The post anesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first?
Client with a blood pressure of 90/50 mm Hg.
Client with a temperature of 96° F (35.6° C).
Client with a pulse of 118 beats/min.
Client with a respiratory rate of 6 breaths/min.
The Correct Answer is D
A. A blood pressure of 90/50 mm Hg is concerning, but it is less urgent than severe respiratory depression. The nurse should still assess this client promptly.
B. A temperature of 96° F (35.6° C) is mildly low and should be addressed, but it is not as critical as a severely low respiratory rate.
C. A pulse of 118 beats/min is elevated and may require monitoring, but it does not pose as immediate a threat as respiratory depression.
D. A respiratory rate of 6 breaths/min is critically low, which may indicate respiratory depression, particularly after anesthesia. Immediate assessment and intervention are needed to ensure adequate oxygenation and ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. P wave touching the T wave can indicate an issue but is less urgent than chest pain.
B. Midsternal chest pain could indicate myocardial ischemia or infarction, requiring immediate intervention.
C. Increased urine output is not an urgent concern in this context.
D. Mild orthostatic hypotension is not as urgent as chest pain.
Correct Answer is D
Explanation
A. Appling a paper bag over the client's nose and mouth is used for hyperventilation or respiratory alkalosis, not for respiratory acidosis. In this case, it would worsen the client’s condition by increasing CO2 retention.
B. Administering 50 mL of 20% glucose and 20 units of regular insulin is appropriate for hyperkalemia or diabetic ketoacidosis, not respiratory acidosis following a seizure.
C. Administering 50 mL of sodium bicarbonate intravenously is used for severe metabolic acidosis. This client’s acidosis is primarily respiratory in origin, making this choice inappropriate.
D. Applying oxygen by mask or nasal cannula helps correct the low oxygen levels and supports respiration post-seizure.
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