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. Serum insulin levels reflects short-term insulin secretion but does not indicate long-term glucose control.

B. Hemoglobin levels relate to anemia, not glucose control.

C. Hemoglobin A1C level reflects the average blood glucose over the past 2-3 months, providing an excellent measure of long-term control.

D. Fingerstick fasting blood glucose level reflects glucose levels at the moment of testing, not long-term control.

A. "Clean the skin and clip hairs if needed." B. "Turn off oxygen prior to monitoring the client." C. "Place the electrodes on the posterior chest." D. "Add gel to the electrodes prior to applying them."

Correct Answer is A

Explanation

A. Cleaning the skin and clipping hairs ensures good electrode contact, which is essential for accurate ECG readings. This is the correct statement.

B. Oxygen should not be turned off unless specifically instructed by a provider. It does not interfere with ECG monitoring.

C. Electrodes should be placed on the anterior chest for standard ECG monitoring, not on the posterior chest.

D. Electrodes for ECG monitoring typically come with adhesive backing and do not require additional gel.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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