A nurse is caring for a client who is receiving meperidine. Which of the following is the nurse's priority assessment before administering the medication?
Urinary retention
Vomiting
Respiratory rate
Level of consciousness
The Correct Answer is C
A. Urinary retention: While urinary retention can be a side effect of meperidine and other opioids, it is not the priority assessment before administering the medication. Urinary retention is a concern but is not immediately life-threatening compared to other potential side effects of opioids, such as respiratory depression. Assessing urinary retention is important, but it is not the primary concern in this situation.
B. Vomiting: Vomiting can also be a side effect of opioids, including meperidine. While it is essential to assess for vomiting and its potential impact on the client's overall condition, it is not the priority assessment before administering the medication. Vomiting can be managed, and the nurse should address it as needed. However, the priority assessment is one that can affect the client's immediate safety and well-being, such as respiratory rate and potential respiratory depression.
C. Respiratory rate: This is the correct answer. The priority assessment before administering meperidine is the client's respiratory rate. Opioids can cause respiratory depression, leading to reduced breathing and inadequate ventilation. Monitoring the respiratory rate allows the nurse to detect any signs of respiratory distress or inadequate breathing, enabling them to intervene promptly to prevent serious complications.
D. Level of consciousness: While assessing the client's level of consciousness is essential for overall assessment and monitoring, it is not the priority assessment before administering meperidine. Respiratory depression due to opioid use can occur even when the client is conscious. However, if respiratory depression occurs, it can lead to a decrease in consciousness and potentially unconsciousness, making the assessment of respiratory rate more critical to prevent such complications.
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Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is A
Explanation
The nurse should include lightheadedness as an adverse effect in the teaching for a client who has a new prescription for atenolol. Atenolol is a beta-blocker medication used to treat various conditions, including hypertension and certain heart conditions. One of the common side effects of beta-blockers is orthostatic hypotension, which can cause lightheadedness or dizziness when the client stands up from a sitting or lying position.
Let's go through the other options:
B. Tachycardia: Tachycardia is not an adverse effect of atenolol. In fact, atenolol is used to treat tachycardia by slowing down the heart rate.
C. Dry mouth: Dry mouth is not a typical adverse effect of atenolol. Dry mouth is more commonly associated with anticholinergic medications rather than beta-blockers like atenolol.
D. Bronchodilation: Bronchodilation is not an adverse effect of atenolol. In contrast, atenolol can cause bronchoconstriction (narrowing of the airways) in some individuals, particularly those with asthma or chronic obstructive pulmonary disease (COPD).
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