A nurse in the PACU is caring for a client who received isoflurane. Which of the following assessments is the nurse's priority?

Intake and output

Non verbal pain cues

Bowel sounds

Blood pressure

Answer and Explanation

The Correct Answer is D

A. Intake and output: Monitoring intake and output is essential in the postoperative care of a client to assess fluid balance and kidney function. However, it is not the priority assessment when the client has received isoflurane in the PACU. The priority assessment in this situation is related to the potential cardiovascular side effect of isoflurane, which is hypotension. Hypotension can have immediate and significant implications for the client's perfusion and overall well-being, requiring prompt attention and intervention.

B. Non-verbal pain cues: Assessing for pain is important in the postoperative period to ensure adequate pain management and comfort for the client. However, it is not the priority assessment when the client has received isoflurane in the PACU. The priority assessment at this time is related to the potential cardiovascular impact of the anesthesia, which is blood pressure. Addressing hypotension takes precedence over pain assessment as it poses a more immediate threat to the client's well-being.

C. Bowel sounds: Assessing bowel sounds is part of a comprehensive postoperative assessment to monitor the return of bowel function after surgery. While it is important, it is not the priority assessment when the client has received isoflurane in the PACU. The priority assessment in this situation is related to the potential cardiovascular side effect of the anesthesia, which is blood pressure. Monitoring and managing hypotension is of greater concern in the immediate postoperative period.

D. Blood pressure: This is the correct answer. The priority assessment for a client who received isoflurane in the PACU is the blood pressure. Isoflurane is an inhalation anesthetic that can cause hypotension (low blood pressure). Monitoring the client's blood pressure is crucial to promptly identify and address any hypotension, as it can lead to inadequate tissue perfusion and oxygenation. Addressing blood pressure deviations is essential for the client's cardiovascular stability and overall recovery in the PACU.

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Correct Answer is A

Explanation

When providing teaching to a client with chronic rheumatoid arthritis who is starting a new prescription for hydroxychloroquine, the nurse should instruct the client to obtain routine eye examinations. Hydroxychloroquine is an antimalarial and immunosuppressive medication commonly used to treat rheumatoid arthritis and other autoimmune conditions.

One of the potential side effects of hydroxychloroquine is ocular toxicity, particularly affecting the retina. Retinal toxicity can lead to vision changes or, in severe cases, irreversible damage to the eyes. Therefore, regular eye examinations are necessary to monitor for any signs of retinal toxicity and detect any visual changes early to prevent further complications.

The American Academy of Ophthalmology recommends that patients taking hydroxychloroquine undergo a baseline eye examination before starting the medication and annual eye examinations thereafter, especially after five years of continuous use.

Let's go through the other options:

B. Chest x-ray: A chest x-ray is not routinely required for monitoring clients taking hydroxychloroquine for rheumatoid arthritis. Hydroxychloroquine is not known to cause significant respiratory or pulmonary side effects.

C. Pancreatic enzyme levels: Monitoring pancreatic enzyme levels is not specifically related to hydroxychloroquine therapy. Pancreatic enzyme level testing is typically used to assess the function of the pancreas in conditions like pancreatitis or pancreatic insufficiency.

D. Urinalysis screening: While regular monitoring of kidney function is important for clients on long-term medication therapy, routine urinalysis screening is not specifically related to hydroxychloroquine use in clients with rheumatoid arthritis. Regular eye examinations are of higher priority due to the potential ocular toxicity associated with this medication.

A. Hgb 14 g/dL B. WBC count 10,000/mm3 C. INR 2.0 D. Platelets 150,000/mm3

Correct Answer is C

Explanation

A. Hemoglobin level: The hemoglobin level measures the amount of hemoglobin, the oxygen-carrying protein in red blood cells, in the blood. Warfarin is not directly responsible for increasing or decreasing the hemoglobin level. While warfarin can lead to bleeding complications in some cases, it does not specifically target the hemoglobin level, so it is not a direct indicator of the medication's effectiveness.

B. Platelet count: The platelet count measures the number of platelets in the blood, which are essential for blood clotting. Warfarin does not directly affect platelet production or count. It works by inhibiting the production of certain clotting factors, not by affecting platelets. Monitoring the platelet count is important, but it is not an indicator of warfarin's effectiveness in preventing excessive clotting.

C. Prothrombin time (PT) or activated partial thromboplastin time (aPTT): Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are coagulation tests used to assess different types of anticoagulant medications, such as heparin. Warfarin's effect is measured using the International Normalized Ratio (INR). PT and aPTT are not specific to warfarin therapy and are not used to monitor its effectiveness. The INR is the appropriate laboratory test for assessing the efficacy of warfarin therapy.

D. International Normalized Ratio (INR): This is the correct answer. The International Normalized Ratio (INR) is the laboratory test used to monitor the effectiveness of warfarin therapy. The INR measures the time it takes for the blood to clot and reflects the anticoagulant effect of warfarin. A therapeutic INR within the target range (e.g., INR = 2.0 to 3.0 for most indications) indicates that warfarin has been effective in preventing excessive clotting and reducing the risk of complications associated with blood clots.

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A nurse in the PACU is caring for a client who received isoflurane. Which of the following assessments is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has chronic rheumatoid arthritis and a new prescription for hydroxychloroquine. The nurse should instruct the client to obtain which of the following diagnostic studies routinely?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory results of a client who has been taking warfarin for 3 months. Which of the following laboratory results Indicates that the medication has been effective?

Correct Answer is C

Explanation

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