Difficulty: Medium
Average Score: 81%
Simulated
The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)
Correct answer
B,C
Rationale
Correct Answer: B, C
Rationale:
1. Absence of gag reflex (Choice B) can indicate a risk of aspiration and airway compromise, necessitating further monitoring and intervention before transfer.
2. Respiratory rate of 6 breaths per minute (Choice C) is significantly low, indicating respiratory distress and potential respiratory failure, requiring immediate attention before transfer.
Summary:
- Presence of cough (Choice A) is not a contraindication for transfer and may actually be a positive sign of airway clearance.
- Urine output of 90 mL/hour (Choice D) within normal range indicates adequate kidney function.
- Heart rate of 70 beats per minute (Choice E) within normal range does not pose a significant concern for transfer.
- Capillary refill less than 3 seconds (Choice F) is a positive sign of adequate perfusion and does not delay transfer.
Rationale:
1. Absence of gag reflex (Choice B) can indicate a risk of aspiration and airway compromise, necessitating further monitoring and intervention before transfer.
2. Respiratory rate of 6 breaths per minute (Choice C) is significantly low, indicating respiratory distress and potential respiratory failure, requiring immediate attention before transfer.
Summary:
- Presence of cough (Choice A) is not a contraindication for transfer and may actually be a positive sign of airway clearance.
- Urine output of 90 mL/hour (Choice D) within normal range indicates adequate kidney function.
- Heart rate of 70 beats per minute (Choice E) within normal range does not pose a significant concern for transfer.
- Capillary refill less than 3 seconds (Choice F) is a positive sign of adequate perfusion and does not delay transfer.