A nurse is caring for a client who is mechanically ventilated and receiving propofol intravenously. Which of the following manifestations should the nurse identify as a complication of administration?

Hypokalemia

Sepsis

Urinary retention

Hypoglycemia

Answer and Explanation

The Correct Answer is B

B) Sepsis: Propofol is an intravenous sedative-hypnotic agent commonly used for sedation in mechanically ventilated patients. While propofol itself does not directly cause sepsis, its use can increase the risk of sepsis-related complications, such as infection. Propofol is typically administered intravenously, and improper handling or contamination of equipment, including intravenous lines and medication vials, can introduce pathogens into the bloodstream, leading to bloodstream infections (sepsis). Additionally, prolonged use of propofol may suppress immune function, further increasing the susceptibility to infection. Therefore, the nurse should monitor the client for signs and symptoms of sepsis, such as fever, chills, hypotension, tachycardia, and altered mental status, as a potential complication of propofol administration.

A) Hypokalemia: Hypokalemia, or low potassium levels, is not a common complication directly associated with propofol administration. While electrolyte imbalances may occur in critically ill patients, especially those receiving mechanical ventilation, hypokalemia is more likely to result from other factors such as diuretic therapy, gastrointestinal losses, or inadequate potassium intake.

C) Urinary retention: Urinary retention is not a typical complication of propofol administration. While sedative medications like propofol can affect bladder function, causing urinary retention in some cases, it is not a commonly reported complication of propofol use in mechanically ventilated patients.

D) Hypoglycemia: Hypoglycemia, or low blood sugar levels, is a potential complication of propofol administration, particularly in critically ill patients who may have altered glucose metabolism. However, hypoglycemia is not as commonly associated with propofol use as sepsis-related complications. Close monitoring of blood glucose levels is essential when administering propofol, especially if the client has preexisting diabetes mellitus or other risk factors for hypoglycemia. However, sepsis is a more direct and significant complication associated with propofol administration in mechanically ventilated patients.

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Correct Answer is D

Explanation

A) Increased urinary output: Ondansetron is a 5-HT3 receptor antagonist commonly used to prevent and treat nausea and vomiting, particularly in chemotherapy-induced nausea and vomiting and postoperative nausea and vomiting. While increased urinary output may be indicative of improved hydration status or renal function, it is not a direct indicator of ondansetron's effectiveness in controlling nausea and vomiting. Therefore, it is not the most appropriate finding to assess the effectiveness of ondansetron.

B) Reduced dizziness: Ondansetron primarily targets nausea and vomiting by blocking serotonin receptors in the gastrointestinal tract and the chemoreceptor trigger zone. While dizziness may sometimes accompany nausea and vomiting, its reduction may not directly correlate with the effectiveness of ondansetron. Additionally, dizziness can have various causes beyond nausea and vomiting, such as orthostatic hypotension or vestibular dysfunction. Therefore, reduced dizziness alone may not reliably indicate the effectiveness of ondansetron.

C) Absence of peripheral neuropathy: Peripheral neuropathy refers to damage or dysfunction of peripheral nerves, commonly resulting in symptoms such as numbness, tingling, or weakness in the extremities. Ondansetron is not indicated for the treatment of peripheral neuropathy, and its effectiveness in controlling nausea and vomiting would not directly influence the presence or absence of peripheral neuropathy. Therefore, this finding is unrelated to the effectiveness of ondansetron in managing nausea and vomiting.

D) Decreased nausea: Ondansetron is primarily prescribed to alleviate nausea and vomiting associated with various conditions. Therefore, a decrease in nausea would indicate that ondansetron is effective in achieving its therapeutic goal. Assessing the client's level of nausea and observing a reduction in nausea symptoms after administering ondansetron is a direct and appropriate way to evaluate its effectiveness in controlling nausea and vomiting. Thus, decreased nausea is the most accurate indicator of ondansetron's effectiveness among the options provided.

A. Blood pressure B. Pain level C. Breath sounds D. Heart rate

Correct Answer is C

Explanation

A) Blood pressure: While monitoring blood pressure is important, assessing breath sounds takes priority after administering naloxone. Opioid toxicity can lead to respiratory depression, so ensuring adequate ventilation is crucial. Assessing breath sounds helps determine if the client's airway is clear and if ventilation has improved after naloxone administration.

B) Pain level: Pain assessment is important, but it is not the priority after administering naloxone for opioid toxicity. Respiratory status takes precedence due to the risk of respiratory depression associated with opioid overdose.

C) Breath sounds: This is the correct intervention. Naloxone reverses the effects of opioids, including respiratory depression. Assessing breath sounds allows the nurse to evaluate the client's respiratory status and determine the effectiveness of naloxone in improving ventilation.

D) Heart rate: Monitoring heart rate is important, but it is not the priority immediately after administering naloxone. Respiratory assessment takes precedence due to the risk of respiratory depression associated with opioid overdose.

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A nurse is caring for a client who is mechanically ventilated and receiving propofol intravenously. Which of the following manifestations should the nurse identify as a complication of administration?

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Correct Answer is C

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