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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Free Nursing Study Resources

Correct Answer is ["18.8"]

Explanation

To calculate the rate at which the IV pump should deliver dopamine, we can follow these steps:

Step 1: Convert the weight of the client from pounds to kilograms.

220 lb ÷ 2.2 = 100 kg (rounded to the nearest whole number)

Step 2: Calculate the total dose of dopamine per minute.

5 mcg/kg/min × 100 kg = 500 mcg/min

Step 3: Convert the dose from micrograms (mcg) to milligrams (mg).

500 mcg/min ÷ 1000 = 0.5 mg/min

Step 4: Determine the infusion rate in milliliters per hour (mL/hr).

The total volume of the solution is 250 mL.

The total dose of dopamine is 400 mg.

So, the infusion rate is (0.5 mg/min ÷ 400 mg) × 250 mL = 0.3125 mL/min.

Step 5: Convert the infusion rate from mL/min to mL/hr.

0.3125 mL/min × 60 min/hr = 18.75 mL/hr (rounded to the nearest tenth).

Therefore, the nurse should set the IV pump to deliver 18.8 mL/hr (rounded to the nearest tenth).

A. This medication can cause your urine to turn orange." B. "You should take this medication with food." C. This medication can cause insomnia D. You should take a stool softener with this medication

Correct Answer is A

Explanation

The nurse should include the statement that rifampin can cause the client's urine to turn orange. Rifampin is an antibiotic commonly used to treat tuberculosis and other bacterial infections. One of its common side effects is discoloration of bodily fluids, including urine, saliva, sweat, and tears. This discoloration is harmless and is not a cause for concern. Informing the client about this side effect helps prevent unnecessary worry or alarm.

"You should take this medication with food" (B) is not specifically related to rifampin. However, taking rifampin with food can help reduce gastrointestinal side effects such as stomach upset or nausea.

"This medication can cause insomnia" (C) is not a common side effect of rifampin. Insomnia is more commonly associated with certain other medications or medical conditions.

"You should take a stool softener with this medication" (D) is not necessary for rifampin. Stool softeners are typically used to alleviate constipation, but rifampin does not commonly cause constipation as a side effect.

Therefore, the nurse should primarily include the statement that rifampin can cause the client's urine to turn orange.

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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 ["18.8"]

Explanation

A nurse is providing teaching for a client who has a new prescription for rifampin. Which of the following statements should the nurse include?

Correct Answer is A

Explanation

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