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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?

A.

Intake and output

B.

Non verbal pain cues

C.

Bowel sounds

D.

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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Related Questions

Correct Answer is C

Explanation

Exenatide is a medication used to treat type 2 diabetes mellitus. The nurse should plan to administer exenatide via the subcutaneous route.

Subcutaneous administration involves injecting the medication into the fatty tissue just below the skin. Exenatide is available as a subcutaneous injection and is typically given in the abdomen, thigh, or upper arm.

Let's go through the other options:

A. Oral: Exenatide is not available in an oral form. It is a peptide-based medication that would be destroyed by stomach acid and digestive enzymes if taken orally. Therefore, it must be administered via injection to be effective.

B. Intramuscular: Exenatide is not administered intramuscularly. Intramuscular injections are given deep into the muscle tissue, and exenatide is not formulated or intended for this route of administration.

D. Intravenous: Exenatide is not administered intravenously. Intravenous injections are given directly into the bloodstream, and exenatide is not suitable for this route of administration.

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.

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