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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When assessing a client receiving ciprofloxacin, the nurse should prioritize reporting tendon pain when walking to the provider. Ciprofloxacin is a fluoroquinolone antibiotic that can rarely cause tendonitis or tendon rupture, particularly in the Achilles tendon. Tendon pain, especially when associated with difficulty walking, can be indicative of a serious adverse effect and requires immediate attention and evaluation by the provider.
Nausea and vomiting (A) are common side effects of ciprofloxacin but are typically not considered urgent or life-threatening. They can often be managed with supportive care measures and may not require immediate intervention.
Daytime drowsiness (B) is not typically associated with ciprofloxacin and may be unrelated to the medication. It should be assessed and reported if it persists or is severe, but it is not a priority finding specifically related to ciprofloxacin administration.
Photosensitivity (D) is a known side effect of ciprofloxacin, but it is not typically considered a priority finding unless it is severe or causing significant discomfort. Adequate sun protection measures can help manage photosensitivity.
Correct Answer is A
Explanation
Neonatal abstinence syndrome (NAS) is a group of withdrawal symptoms that occur in newborns who were exposed to drugs, including heroin, in utero. Hyporeflexia, which refers to reduced or diminished reflexes, is one of the key findings in neonates experiencing NAS.
During pregnancy, when the mother uses opioids like heroin, the baby becomes dependent on the drug. After birth, when the drug is no longer available, the baby experiences withdrawal symptoms as the body adjusts to the absence of the drug. Hyporeflexia is a common manifestation of NAS and is observed due to the central nervous system's response to the withdrawal.
Let's go through the other options:
B. Frequent yawning: While yawning can be seen in neonates with NAS, it is not as specific to the condition as hyporeflexia. Yawning can occur for various reasons and may not always be indicative of NAS.
C. Respiratory depression: Respiratory depression can be a severe complication of opioid exposure in utero and can result in life-threatening situations for the neonate. However, it is not specific to NAS. Respiratory depression is more closely associated with opioid overdose in the newborn, which can be a separate concern from NAS.
D. Constipation: Constipation is a possible symptom in neonates experiencing NAS, but it is not as specific as hyporeflexia. Constipation can occur due to various factors and is not unique to NAS.
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