A nurse is caring for an adolescent who is postoperative following epidural anesthesia. Which of the following findings should the nurse expect?
Hypertension
Mild sedation
Urinary retention
Respiratory depression
The Correct Answer is C
A. "Hypertension" Epidural anesthesia typically causes hypotension, not hypertension, due to vasodilation and decreased sympathetic nervous system activity.
B. "Mild sedation" While some systemic absorption of anesthetics may occur, epidural anesthesia primarily affects sensory and motor function rather than causing significant sedation.
C. "Urinary retention" Epidural anesthesia can inhibit bladder sensation and detrusor muscle function, leading to urinary retention. The nurse should monitor urine output and assess for bladder distention.
D. "Respiratory depression" While respiratory depression can occur with high doses of opioids administered through an epidural, it is not a common expected effect of epidural anesthesia alone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]
Explanation
- Heart rate 104/min – The heart rate has decreased from 114/min on Day 1, indicating improvement.
- Respiratory rate 24/min – The respiratory rate has decreased from 26/min, showing stabilization.
- SpO₂ 98% on room air – Oxygen saturation remains stable and adequate.
- Mucous membranes pink and moist – Indicates improved hydration.
- Radial pulse 2+ bilateral – Stronger pulse compared to the previous day’s 1+, suggesting better circulation.
- Capillary refill less than 2 seconds – Improved from the previous day’s delayed refill (4 seconds), showing better perfusion.
- Extremities warm and dry to touch – Indicates adequate circulation and hydration.
- Good skin turgor – Suggests the child is well-hydrated.
- Bowel sounds active in all 4 quadrants – Indicates normal gastrointestinal function.
- Breath sounds clear anterior and posterior bilaterally – No respiratory distress or abnormal findings.
Findings that do not indicate improvement:
- Temperature 38.9°C (102°F) – Slightly higher than the previous day (38.7°C), suggesting persistent fever.
- Drowsy and lethargic – The child is still lethargic, which may indicate ongoing illness.
- Nuchal rigidity present – No improvement in meningitis-related symptoms.
- Cervical lymph slightly enlarged – Indicates ongoing immune response.
Correct Answer is D
Explanation
A. "Temperature 38.6° C (101.5° F)." A fever is not an indicator of improved hydration or effective fluid resuscitation. It may be related to an underlying infection, which could contribute to hypovolemia.
B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration, indicating that the fluid replacement was not fully effective. If the treatment were successful, the fontanel should be normal (flat and soft).
C. "Tachycardia." Tachycardia is a sign of ongoing hypovolemia or distress. If fluid resuscitation was effective, the heart rate should return to normal for the infant's age.
D. "Capillary refill is 2 seconds." A capillary refill time of 2 seconds or less indicates adequate peripheral perfusion and improved circulation, showing that the fluid bolus was effective in restoring blood volume and perfusion.
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