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

Poorly controlled pain, moves all extremities, reports continued nausea

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

Afebrile, adventitious breath sounds, responds to painful stimuli

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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Correct Answer is B

Explanation

A. Hypernatremia: This condition involves elevated sodium levels, which is not directly addressed by the insulin and dextrose order.
B. Hyperglycemia: While dextrose can exacerbate hyperglycemia, the order of insulin and dextrose is not for managing hyperglycemia but for another purpose.
C. Hypercalcemia: This condition involves elevated calcium levels and is not related to the use of insulin and dextrose.
D. Hyperkalemia: The administration of regular insulin with dextrose is often used to manage hyperkalemia. Insulin helps shift potassium into cells, while dextrose prevents hypoglycemia resulting from the insulin.

A. 0.45% Sodium Chloride B. 10% dextrose in water C. 5% dextrose in water D. 0.9% Sodium Chloride

Correct Answer is D

Explanation

A. 0.45% Sodium Chloride: This is a hypotonic solution, which is not appropriate for a client with normal serum osmolality (290 mOsm/kg). It may cause fluid shifts that are not desirable in this context.
B. 10% dextrose in water: This hypertonic solution is generally used for providing calories rather than correcting fluid imbalance and is not suitable for initial rehydration in this scenario.
C. 5% dextrose in water: This solution is isotonic in the bag but becomes hypotonic in the body. It is not the best choice for rehydrating a client with normal serum osmolality and significant fluid loss.
D. 0.9% Sodium Chloride: This isotonic solution is appropriate for rehydration in a client with normal serum osmolality. It helps restore extracellular fluid volume without causing fluid shifts, making it ideal for this situation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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