The nurse is assessing a client in the Post-Anesthesia Care Unit who received an epidural block for left knee surgery 4-hours ago. For each assessment finding related to epidural anesthesia, click to specify if the finding is appropriate or inappropriate for the nurse to immediately report to the healthcare provider. (Select All That Apply)
Total urine output 45 mL curing past 3 hours
Nausea and vomiting
Clear fluid leaking from insertion site
Severe headache
Left knee pain 3 out of 10
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Total urine output 45 mL during past 3 hours: Appropriate
Rationale: Epidural anesthesia can affect bladder function, leading to reduced urine output. A total urine output of 45 mL in 3 hours is low and should be reported as it might indicate urinary retention or decreased kidney function.
Nausea and vomiting: Inappropriate
Rationale: Nausea and vomiting are not typically a direct concern related to epidural anesthesia unless they are severe or persistent. These symptoms are more commonly associated with general anesthesia or postoperative complications, but they are not immediate concerns specific to epidural block.
Clear fluid leaking from insertion site: Appropriate
Rationale: Clear fluid leaking from the epidural insertion site could indicate cerebrospinal fluid leakage or other complications. This should be reported immediately to assess for potential complications such as an epidural hematoma or infection.
Severe headache: Appropriate
Rationale: A severe headache following an epidural block could be a sign of a post-dural puncture headache, which is a known complication of epidural anesthesia. It should be reported to the healthcare provider for further evaluation and management.
Left knee pain 3 out of 10: Inappropriate
Rationale: Pain at a level of 3 out of 10 is relatively mild and may be expected following surgery. While it is important to monitor and manage pain, this level of pain is not usually an immediate concern related to the epidural anesthesia unless other symptoms are present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. Reddish streak proximal to the insertion site: This indicates phlebitis, not infiltration.
B. Skin is pale and taut: This indicates infiltration as fluid accumulates in the surrounding tissue, causing the skin to appear pale and tight.
C. The vein is firm and cord-like: This is typically a sign of phlebitis or thrombophlebitis, not infiltration.
D. IV fluid leaking from insertion site: This is a sign of infiltration where fluid has leaked out of the vein into the surrounding tissue.
E. Warmth at the insertion site: This can indicate infiltration or inflammation, depending on other symptoms present.
Correct Answer is D
Explanation
A. Level of consciousness: While important, it follows the assessment of vital signs to ensure the client's overall stability.
B. Condition of drains: This is relevant but not as immediate as assessing the stability of vital signs.
C. Appearance of the surgical dressing: This is important but secondary to ensuring the client’s vital signs are stable.
D. Stability of vital signs: This is the most critical next assessment after ensuring a patent airway, as vital signs reflect the client's immediate physiological status and stability.
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