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 A
Explanation
When a medication error occurs, the nurse should report the incident to the nurse manager or appropriate supervisor. It is essential to follow the facility's policies and procedures for reporting and managing medication errors. Prompt reporting allows for appropriate investigation, documentation, and implementation of necessary measures to prevent future errors.
Documenting that the pharmacy sent the incorrect medication (B) is not appropriate in this situation, as it does not address the nurse's role and responsibility in the error. Reporting the incident is the primary action required.
Contacting the provider to change the client's prescription (C) is not necessary in this case, as the error was related to the medication selection during administration, not an issue with the prescription itself.
Placing the unwrapped celecoxib back into the AMDS (D) is not appropriate. Once a medication has been removed from its packaging or container, it should not be returned to the dispensing system. Additionally, since it was the wrong medication for the client, it should not be administered.
Therefore, the nurse should primarily report the incident to the nurse manager or appropriate supervisor to ensure appropriate handling of the medication error.
Correct Answer is C
Explanation
Flumazenil is the antidote for diazepam, which is a benzodiazepine. Flumazenil is a selective antagonist that can reverse the sedative effects of benzodiazepines and is commonly used in cases of benzodiazepine overdose or to reverse sedation after procedures.
Naloxone (A) is the antidote for opioid overdose and would not be appropriate for reversing the effects of diazepam.
Atropine (B) is an anticholinergic medication used to increase heart rate and is not specific to the reversal of diazepam sedation.
Neostigmine (D) is a cholinesterase inhibitor used to reverse the effects of non-depolarizing neuromuscular blocking agents and is not indicated for reversing the effects of diazepam.
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