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

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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Correct Answer is ["200"]

Explanation

To determine the infusion rate in mL/h, we need to divide the total volume (100 mL) by the total time (30 minutes) and then convert the result to hours.

100 mL / 30 min = 3.33 mL/min

To convert minutes to hours, we multiply by 60:

3.33 mL/min * 60 min/h = 199.8 mL/h

Rounding to the nearest whole number, the nurse should set the IV infusion pump to deliver 200 mL/h.

A. Potassium level B. Creatinine level C. Platelet count D. Liver enzymes

Correct Answer is B

Explanation

Before administering the first dose of metformin, the nurse should evaluate the client's creatinine level. Metformin is primarily excreted by the kidneys, and its clearance from the body depends on the renal function. If the client has impaired kidney function, metformin can accumulate in the body and lead to potential adverse effects, particularly lactic acidosis.

Monitoring the creatinine level helps assess the client's kidney function and determines whether it is safe to administer metformin. If the creatinine level is elevated, indicating reduced kidney function, the nurse should consult with the healthcare provider to determine the appropriate dose adjustment or consider an alternative treatment option.

Let's go through the other options and explain why they are not the priority laboratory results to evaluate before administering metformin:

A. Potassium level: While monitoring potassium levels is important in some situations, it is not a primary concern before administering metformin. Metformin does not have a significant effect on potassium levels, and it is not a medication known for causing hypokalemia (low potassium levels).

C. Platelet count: Metformin does not have a direct impact on platelet count, and evaluating platelet count is not typically required before starting metformin therapy. Platelet count monitoring may be relevant for certain other medications or medical conditions, but it is not specific to metformin administration.

D. Liver enzymes: While it is essential to monitor liver function in clients on long-term metformin therapy, evaluating liver enzymes before the first dose of metformin is not the priority. Metformin is primarily cleared by the kidneys, and liver enzymes are not directly affected by its initial administration. However, ongoing monitoring of liver function may be necessary during long-term

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["200"]

Explanation

A nurse is caring for a client who has a new prescription for metformin. Which of the following laboratory results should the nurse evaluate prior to administering the first dose?

Correct Answer is B

Explanation

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