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 D

Explanation

A. Neuromuscular blockers: These are used to induce paralysis and do not affect consciousness or maintain reflexes such as the gag reflex.
B. Inhaled general anesthesia: Generally, inhaled general anesthesia suppresses all reflexes, including the gag reflex.
C. Intravenous general anesthesia: This type of anesthesia typically induces a loss of consciousness and suppression of reflexes, including the gag reflex.
D. Regional anesthesia: This type of anesthesia blocks sensation in a specific area of the body while the client remains conscious and retains reflexes, including the gag reflex.

A. Pulmonary embolism B. Pneumonia C. Hemorrhage D. Myocardial infarction

Correct Answer is A

Explanation

A. Pulmonary embolism: Pulmonary embolism presents with sudden onset of chest pain, tachycardia, hypotension, and restlessness, which aligns with the client's symptoms. It is a common postoperative complication due to immobility and potential hypercoagulability.
B. Pneumonia: Pneumonia typically develops more gradually and presents with fever, productive cough, and respiratory distress rather than sudden chest pain and hemodynamic instability. It is less likely in the immediate postoperative period.
C. Hemorrhage: Hemorrhage would also cause tachycardia and hypotension, but it would typically present with symptoms such as excessive bleeding, swelling at the surgical site, and pallor rather than chest pain.
D. Myocardial infarction: While myocardial infarction can cause chest pain, tachycardia, and hypotension, it is less likely in this scenario compared to a pulmonary embolism, given the timing and nature of the symptoms in the immediate postoperative period.

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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

The nurse is educating a group of student nurses about the different types of anesthesia. The student demonstrates an understanding of the teaching when they state that a client would maintain a gag reflex with what anesthesia?

Correct Answer is D

Explanation

The nurse is rounding on a client who is 12 hours postoperative. Upon assessment, the client becomes tachycardic, hypotensive, and restless and complains of sudden chest pain. Which postoperative complication should the nurse conclude that the client most likely experienced?

Correct Answer is A

Explanation

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