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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Oxybutynin is an anticholinergic medication commonly used to treat urinary incontinence. One of the adverse effects of anticholinergic medications is the potential for bradycardia, which refers to a slower than normal heart rate. Anticholinergic medications can inhibit the effects of acetylcholine, a neurotransmitter responsible for regulating various bodily functions, including heart rate. Therefore, it is important to assess the client for signs of bradycardia after an unintended higher dose of oxybutynin.
Increased salivation (A) is not an expected adverse effect of oxybutynin. In fact, anticholinergic medications like oxybutynin often have the opposite effect, causing dry mouth and reduced salivation.
Hyperthermia (B) is not a typical adverse effect of oxybutynin. It is more commonly associated with other conditions or medications.
Urinary incontinence (C) is the condition that oxybutynin is intended to treat. It is not an adverse effect but rather the therapeutic effect of the medication.
Correct Answer is B
Explanation
A. History of asthma:Verapamil is a calcium channel blocker and does not affect the airways or cause bronchospasm, unlike beta-blockers, which can exacerbate asthma.
B. History of heart failure:Verapamil has negative inotropic effects, meaning it decreases the strength of heart contractions. This can exacerbate heart failure, particularly in clients with reduced ejection fraction (systolic heart failure). It is generally contraindicated in clients with severe heart failure as it can worsen symptoms.
C. Systolic BP 110 mm Hg:While verapamil can cause a drop in blood pressure due to its vasodilatory effects, a systolic blood pressure of 110 mm Hg is not an absolute contraindication.
D. A blood creatinine level of 1.0 mg/dL is within the normal range (approximately 0.6–1.2 mg/dL for adults). Verapamil is not contraindicated in clients with normal renal function.
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