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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. It is appropriate to monitor for symptoms of bradycardia, but the student is currently asymptomatic.

B. Referral to a cardiologist is not necessary unless the student develops symptoms or other concerning signs.

C. Sinus bradycardia can be normal in young, healthy athletes, especially those who engage in regular physical activity. Since the student is asymptomatic, with no signs of dyspnea, chest pain, or other concerning symptoms, there is no reason to restrict participation in sports.

D. Family history may be helpful, but this is not the immediate priority when the student is asymptomatic.

A. "I am glad that these tubes will fall out at home when I finally shower." B. "I should measure the drainage each day to make sure it is less than an ounce (30 mL)." C. "I should be careful how I lie in bed so that I will not kink the tubing." D. "If there is a foul odor from the drainage, I will contact my primary health care provider."

Correct Answer is A

Explanation

A. This statement indicates that the client may not fully understand the care required for the drainage tubes. Drainage tubes typically do not "fall out" on their own; they need to be removed by a healthcare provider. The client should be instructed to care for the tubes, monitor drainage, and report any concerns to their healthcare provider.

B. It is appropriate to measure the drainage each day and report it if it exceeds the expected amount. This helps ensure that the surgical site is healing properly.

C. The client should be cautious with the positioning of the drainage tubes to avoid kinking or pulling, which could interfere with drainage and cause complications.

D. A foul odor from the drainage could indicate an infection, so it is appropriate for the client to contact their primary healthcare provider if this occurs.

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The post anesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first?

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Naxlex Comprehensive Predictor Exams

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