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Which client response best supports the decision to discharge the client from the Post-Anesthesia Care Unit?

A.

Poorly controlled pain, moves all extremities, reports continued nausea

B.

2-hour total urinary output of 30 mL, pulse oximetry 94% on 3L oxygen, turning from side to side

C.

Afebrile, adventitious breath sounds, responds to painful stimuli

D.

SaO2 of 95%, vital signs stable for last 30 minutes, active gag reflex

Answer and Explanation

The Correct Answer is D

A. Poorly controlled pain, moves all extremities, reports continued nausea: Poorly controlled pain and nausea are not ideal for discharge, as they indicate the patient might need further monitoring and management.
B. 2-hour total urinary output of 30 mL, pulse oximetry 94% on 3L oxygen, turning from side to side: Low urinary output and low oxygen saturation indicate potential complications that require further assessment and treatment.
C. Afebrile, adventitious breath sounds, responds to painful stimuli: Responding to painful stimuli and adventitious breath sounds suggest the patient may still be experiencing complications and is not ready for discharge.
D. SaO2 of 95%, vital signs stable for last 30 minutes, active gag reflex: This response indicates stable oxygen saturation, stable vital signs, and an active gag reflex, suggesting the patient is ready for discharge from the PACU.
 


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Related Questions

Correct Answer is D

Explanation

A. Respiratory rate 24/min: A respiratory rate of 24/min indicates tachypnea, which can be a sign of ongoing fluid volume excess or other complications. This does not show effective treatment.
B. Blood pressure 138/86 mm Hg: While this blood pressure is within the higher range of normal, it does not specifically indicate effective treatment of fluid volume excess. Blood pressure alone is not a reliable indicator of fluid status.
C. Total urinary output 700 mL in 24 hours: A urinary output of 700 mL in 24 hours is below the normal range (typically 800-2000 mL per day) and suggests that the fluid volume excess has not been effectively treated. Adequate urinary output is a key indicator of effective fluid management.
D. Weight loss of 4 lb in 24 hours: A weight loss of 4 lb in 24 hours is a clear indicator that the client has lost excess fluid, which is the desired outcome in treating fluid volume excess. This demonstrates that the treatment has been effective in reducing fluid retention

Correct Answer is C

Explanation

A. Calcium: Thiazide diuretics can increase calcium levels, but the primary concern is the potential loss of potassium.
B. Selenium: This is not directly related to thiazide diuretic therapy and does not address the primary electrolyte imbalance.
C. Potassium: This is the correct choice. Thiazide diuretics can cause hypokalemia (low potassium levels). Encouraging potassium-rich foods helps to counteract this side effect.
D. Bicarbonate: While bicarbonate can be important for acid-base balance, it is not the primary concern with thiazide diuretics, which typically affect potassium levels.

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