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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client statement that indicates an understanding of the teaching is: "The medication can cause drowsiness."
Promethazine is an antihistamine medication commonly used to treat various conditions, such as allergies, motion sickness, and nausea. One of the most common side effects of promethazine is drowsiness or sedation. It has a significant sedative effect, and it is often used to induce sleep or manage insomnia in some cases.
Let's go through the other options:
A. "This medication can cause diarrhea": Diarrhea is not a common side effect of promethazine. While promethazine can cause certain gastrointestinal side effects like constipation or upset stomach, diarrhea is not typically associated with its use.
B. "The medication can cause increased salivation": Increased salivation is not a common side effect of promethazine. While some antihistamines can cause dry mouth, which is the opposite of increased salivation, promethazine does not usually cause excessive salivation.
C. "This medication can cause pupil constriction": Pupil constriction (miosis) is a potential side effect of some medications, but it is not commonly associated with promethazine. Promethazine is more likely to cause pupil dilation (mydriasis) rather than constriction.
Correct Answer is D
Explanation
The nurse should report a creatinine level of 2 mg/dl to the provider as a potential adverse effect of captopril. Captopril is an angiotensin-converting enzyme (ACE) inhibitor commonly used to treat congestive heart failure and hypertension. One of the side effects of ACE inhibitors, including captopril, is the potential to cause kidney problems, leading to an increase in serum creatinine levels.
An increase in serum creatinine may indicate impaired kidney function, and it is essential to monitor kidney function regularly in clients taking ACE inhibitors. Elevated creatinine levels can suggest reduced glomerular filtration rate (GFR) and impaired kidney function, which may require adjustments in medication dosage or further evaluation and management.
Let's go through the other options:
A. Absolute neutrophil count (ANC) 4.000/ mm^3: An absolute neutrophil count of 4.000/ mm^3 is within the normal range, so it is not an adverse effect of captopril that requires immediate reporting.
B. Brain natriuretic peptide (BNP) 90 ng/L: A brain natriuretic peptide (BNP) level of 90 ng/L is used to assess heart failure severity. While BNP levels can be helpful in managing congestive heart failure, a BNP level of 90 ng/L is not an adverse effect of captopril that requires immediate reporting.
C. Sodium 140 mEq/l: A sodium level of 140 mEq/L is within the normal range, so it is not an adverse effect of captopril that requires immediate reporting.
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