A nurse is caring for a client who arrived at the post anesthesia care unit (PACU) following a right knee arthroscopy. The client is not yet responding to verbal stimuli. Which of the following actions should the nurse perform first?

Place the patient in a lateral position.

Apply a warm blanket.

Compare and contrast peripheral pulses.

Assess their dressings.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Placing the patient in a lateral position (recovery position) is critical to maintain an open airway and prevent aspiration, especially in a client who is not responding to verbal stimuli. This position helps ensure that the airway remains clear and reduces the risk of aspiration if the client vomits.

Choice B reason:

Applying a warm blanket is important for maintaining the client’s body temperature but is not the immediate priority when the client is unresponsive. Ensuring airway patency takes precedence.

Choice C reason:

Comparing and contrasting peripheral pulses is part of the assessment process but is not the first priority. Ensuring the client's airway and breathing are secure is more urgent.

Choice D reason:

Assessing dressings is necessary to monitor for bleeding or other complications but is not as immediate as ensuring the client’s airway is clear and protected.

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Correct Answer is A

Explanation

Choice A reason: This is the correct answer. Renal dysfunction is a common concern in older adults and significantly affects the clearance of medications from the body. Impaired kidney function can lead to the accumulation of drugs, increasing the risk of toxicity.

Choice B reason: Pancreatic impairment affects the digestion and absorption of nutrients, but it is not the primary concern related to medication toxicity. The liver and kidneys are more directly involved in drug metabolism and excretion.

Choice C reason: Increased gastric motility is not typically associated with medication toxicity. Slowed gastric emptying is more common in the elderly and can affect drug absorption, but it is not a primary cause of toxicity.

Choice D reason: Increased blood volume is not usually a physiological change in older adults and is not related to medication toxicity. Instead, decreased blood volume and changes in body composition are more typical and can affect drug distribution and metabolism.

A. "This hospital might use a different manufacturer, so you must take the medication." B. "This is the medication prescribed by your provider." C. "What does your usual pill look like?" D. "This pill is probably from a different lot number than yours at home."

Correct Answer is C

Explanation

Choice A reason:

Responding with "This hospital might use a different manufacturer, so you must take the medication" dismisses the client’s concern and does not verify if there has been an error in medication dispensing. It’s important for nurses to validate patient concerns rather than making assumptions about the situation.

Choice B reason:

Stating "This is the medication prescribed by your provider" assumes correctness without verifying the client's concern. Although this reassures the patient of prescription accuracy, it fails to address the immediate discrepancy noted by the client, potentially overlooking a mistake.

Choice C reason:

Asking "What does your usual pill look like?" involves the client in the medication verification process, validating their observation and ensuring that the medication is correct. This response demonstrates respect for the client's knowledge and enhances safety by cross-checking details before administration.

Choice D reason:

Assuming "This pill is probably from a different lot number than yours at home" could be misleading and fails to confirm the medication’s accuracy. It’s important to thoroughly investigate the client’s concern rather than making presumptions about manufacturing details.

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A nurse is caring for a client who arrived at the post anesthesia care unit (PACU) following a right knee arthroscopy. The client is not yet responding to verbal stimuli. Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse closely monitors an older adult for signs of medication toxicity. Which physiological change is the reason for the nurse's concern?

Correct Answer is A

Explanation

A nurse is preparing to administer a medication to a client who states, "That looks different from the pill I usually take." Which is the best response by the nurse?

Correct Answer is C

Explanation

The nurse is preparing to assist in the sedation of a client with propofol (Diprivan) prior to surgery. Which of the following contraindications associated with propofol (Diprivan) should the nurse assess for?

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The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea?

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