Ati Mental Health Proctored Exam 3
Select All That Apply
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.)
Explanation & Rationale
A. The presence of a cough is expected as a protective reflex and does not delay transfer. B. The absence of a gag reflex increases the risk of aspiration, delaying safe transfer. C. A respiratory rate of 6 breaths per minute indicates respiratory depression, which requires immediate intervention. D. Urine output of 90 mL/hour is within the expected range and does not delay transfer. E. A heart rate of 70 beats per minute is normal and not a contraindication for transfer. F. Capillary refill less than 3 seconds is normal and does not delay the transfer.
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