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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I will increase my fluid and fiber intake while I am taking iron tablets.": This statement is correct as increasing fluid and fiber can help manage constipation, a common side effect of iron supplementation.
B. "I will take the tablets with water an hour before eating.": This is correct because taking iron supplements on an empty stomach can improve absorption, and water helps dissolve the tablets.
C. "I will immediately call my health care provider if my stools turn green.": This statement indicates a misunderstanding, as green stools are a common and harmless side effect of iron supplements. They are not typically a cause for concern unless accompanied by other symptoms.
D. "I will take a stool softener if I occasionally feel constipated.": This is a correct and appropriate approach, as stool softeners can help alleviate constipation caused by iron supplements.
Correct Answer is C
Explanation
A. Vomiting: Vomiting is a common symptom associated with metabolic acidosis but is not a compensatory mechanism. It can lead to further electrolyte imbalances and dehydration.
B. Tachycardia: Tachycardia can occur as a response to acidosis but is not a direct compensatory mechanism for metabolic acidosis.
C. Deep rapid breathing: This is the correct choice. Deep rapid breathing, or Kussmaul respirations, is a compensatory mechanism for metabolic acidosis. It helps to expel carbon dioxide, thereby reducing acidity in the blood.
D. Watery diarrhea: Diarrhea can contribute to electrolyte imbalances and may exacerbate acidosis but is not a compensatory response by the body.
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