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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Crush the medication and administer it through the tube: Crushing sustained-release medications can alter their release mechanism, leading to potential overdose or ineffective treatment. Sustained-release formulations should not be crushed.
B. Provide the medication orally for the client to swallow: This option is not appropriate because the client has a gastrostomy tube, and oral administration is not suitable for this route.
C. Ask the healthcare provider to prescribe the medication as an elixir for tube administration: This is the correct approach as it ensures the medication is in a form suitable for administration through the gastrostomy tube without altering its release properties.
D. Dissolve the medication in water and administer it through the tube: Dissolving sustained-release tablets is not recommended as it may compromise the medication's intended release mechanism.

A. "I will increase my fluid and fiber intake while I am taking iron tablets." B. "I will take the tablets with water an hour before eating." C. "I will immediately call my health care provider if my stools turn green." D. "I will take a stool softener if I occasionally feel constipated."

Correct Answer is C

Explanation

A. "I will increase my fluid and fiber intake while I am taking iron tablets.": This statement is correct as increasing fluid and fiber can help manage constipation, a common side effect of iron supplementation.
B. "I will take the tablets with water an hour before eating.": This is correct because taking iron supplements on an empty stomach can improve absorption, and water helps dissolve the tablets.
C. "I will immediately call my health care provider if my stools turn green.": This statement indicates a misunderstanding, as green stools are a common and harmless side effect of iron supplements. They are not typically a cause for concern unless accompanied by other symptoms.
D. "I will take a stool softener if I occasionally feel constipated.": This is a correct and appropriate approach, as stool softeners can help alleviate constipation caused by iron supplements.

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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