Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in the PACU is caring for a client who received isoflurane. Which of the following assessments is the nurse's priority?
A. Intake and output
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
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
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
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.
This question is an excerpt from Nurse Dive's nursing test bank - RN VATI Pharmacology S 2019 Proctored Exam. Take the full exam now
Full 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.
Similar Questions
A nurse is caring for a client who is receiving long-term treatment with oral doses of prednisone. For which of the following adverse effects should the nurse monitor?
A. Hypoglycemia
Hypoglycemia (A) is not a common adverse effect of prednisone. In fact, prednisone can cause hyperglycemia and increase the risk of developing diabetes.
B. Hyperreflexia
Hyperreflexia (B) is not typically associated with prednisone use. Hyperreflexia is an exaggerated reflex response and is not a common adverse effect of corticosteroid therapy.
C. Osteoporosis
The nurse should monitor the client receiving long-term treatment with oral doses of prednisone for the development of osteoporosis. Prednisone is a corticosteroid medication that can lead to decreased bone density and increase the risk of fractures. Prolonged use of prednisone can interfere with calcium absorption and increase bone resorption, leading to osteoporosis.
D. Inflammatory bowel disease
Inflammatory bowel disease (D) is not an adverse effect of prednisone. In fact, prednisone is often used as a treatment for inflammatory bowel disease to reduce inflammation and symptoms.
Full Explanation
The nurse should monitor the client receiving long-term treatment with oral doses of prednisone for the development of osteoporosis. Prednisone is a corticosteroid medication that can lead to decreased bone density and increase the risk of fractures. Prolonged use of prednisone can interfere with calcium absorption and increase bone resorption, leading to osteoporosis.
Hypoglycemia (A) is not a common adverse effect of prednisone. In fact, prednisone can cause hyperglycemia and increase the risk of developing diabetes.
Hyperreflexia (B) is not typically associated with prednisone use. Hyperreflexia is an exaggerated reflex response and is not a common adverse effect of corticosteroid therapy.
Inflammatory bowel disease (D) is not an adverse effect of prednisone. In fact, prednisone is often used as a treatment for inflammatory bowel disease to reduce inflammation and symptoms.
Therefore, the nurse should primarily monitor the client for the development of osteoporosis when receiving long-term treatment with oral doses of prednisone.
A nurse is caring for a client who is receiving diazepam as conscious sedation for an endoscopy, Which of the following antidotes should the nurse have on hand during the procedure?
A. Naloxone
Naloxone (A) is the antidote for opioid overdose and would not be appropriate for reversing the effects of diazepam.
B. Atropine
Atropine (B) is an anticholinergic medication used to increase heart rate and is not specific to the reversal of diazepam sedation.
C. Flumazenil
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.
D. Neostigmine
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.
Full 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.
A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as an adverse effect of TPN
A. 2+ deep tendons reflexes
B. Casual blood glucose 100 mg/dl
C. Potassium 4.8 mEq/L
D. 2+ peripheral pitting Edema
TPN is a form of nutrition given intravenously to provide essential nutrients when a client is unable to consume an adequate oral diet. One of the potential adverse effects of TPN is fluid overload, which can manifest as peripheral edema. The presence of 2+ peripheral pitting edema indicates the accumulation of excess fluid in the tissues. It is important for the nurse to monitor the client's fluid balance closely and assess for signs of fluid overload, such as edema, to prevent complications.
Full Explanation
TPN is a form of nutrition given intravenously to provide essential nutrients when a client is unable to consume an adequate oral diet. One of the potential adverse effects of TPN is fluid overload, which can manifest as peripheral edema. The presence of 2+ peripheral pitting edema indicates the accumulation of excess fluid in the tissues. It is important for the nurse to monitor the client's fluid balance closely and assess for signs of fluid overload, such as edema, to prevent complications.