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. Nuclear medicine scan is less commonly used for diagnosing gastric pain and dyspepsia.

B. Magnetic resonance imaging (MRI) is not the first choice for gastrointestinal issues.

C. Esophagogastroduodenoscopy (EGD) allows direct visualization of the upper GI tract, making it the most accurate diagnostic tool.

D. Abdominal arteriogram is typically used for vascular issues, not for diagnosing dyspepsia or gastric pain.

A. Apply a paper bag over the clients nose and mouth. B. Administer 50 mL of 20% glucose and 20 units of regular insulin. C. Administer 50 mL of sodium bicarbonate intravenously. D. Apply oxygen by mask or nasal cannula.

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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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

The nurse is caring for a client who has frequent gastric pain and dyspepsia. Which procedure would the nurse expect the health care provider to order to make an accurate diagnosis?

Correct Answer is C

Explanation

A client has just experienced a 90-second tonic-clonic seizure and has the following arterial blood gas results: pH 7.12, HCO3 22 mEq/L, PaCO2 55 mmHg, PaO2 60 mmHg. Which intervention is the most appropriate?

Correct Answer is D

Explanation

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