The nurse is caring for a client who had surgery 1 day ago and is receiving a continuous infusion of fentanyl through an epidural catheter. Which intervention should the nurse perform first?

Assess for signs of urine retention.

Inspect epidural catheter insertion site.

Monitor the client's dermatome level for sensation.

Inquire if the client is experiencing breakthrough pain.

Answer and Explanation

The Correct Answer is C

A. Assess for signs of urine retention: While important, urinary retention is a later complication. It does not take priority over assessing for potentially serious effects like respiratory depression or excessive spread of anesthesia.

B. Inspect epidural catheter insertion site: Inspecting the site helps identify infection or dislodgement but is not the first priority. Neurological and respiratory assessments take precedence due to fentanyl’s CNS effects.

C. Monitor the client's dermatome level for sensation: This assesses the spread of the anesthetic, ensuring it hasn’t ascended to high thoracic levels, which could depress respiration. It’s the most urgent check for client safety.

D. Inquire if the client is experiencing breakthrough pain: Pain assessment is critical, but ensuring safe levels of sensory block must come first to rule out excessive anesthetic spread or complications.

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Correct Answer is ["C","D","E"]

Explanation

A. Use standard precautions and wear a mask: Standard precautions are necessary for all patients, but wearing a mask is not specifically required for MRSA unless there is suspicion of respiratory involvement. The focus should be on contact precautions rather than masking.

B. Explain the purpose of a low bacteria diet: A low bacteria diet is not necessary for a client with MRSA unless the client is immunocompromised. The main focus should be on preventing MRSA transmission and managing the infection at the wound site.

C. Send wound drainage for culture and sensitivity: Sending the wound drainage for culture and sensitivity is essential for identifying the causative organism and determining appropriate antibiotic treatment for MRSA. This helps guide therapy and ensure proper management.

D. Institute contact precautions for staff and visitors: Contact precautions are critical for preventing spread of MRSA, especially in wound care situations. The nurse should ensure all staff and visitors follow these precautions to protect others and minimize transmission risk.

E. Monitor the client's white blood cell count: Monitoring the white blood cell count is important as it helps assess the client's immune response to infection. An elevated count may indicate the presence of infection, and close monitoring helps guide treatment decisions.

A. Observe insertion site. B. Assess perineal area. C. Measure abdominal girth. D. Palpate flank area.

Correct Answer is A

Explanation

A. Observe insertion site: The nurse should assess the suprapubic catheter insertion site for signs of infection, redness, or other complications. This is crucial to ensure the catheter is functioning correctly and to prevent infection.

B. Assess perineal area: The perineal area is not directly related to the suprapubic catheter, as it is inserted into the bladder through the abdomen. The focus should be on the insertion site and the catheter itself.

C. Measure abdominal girth: While measuring abdominal girth could be important if the client has issues such as fluid retention or urinary retention, it is not the primary focus for routine assessment of a suprapubic catheter.

D. Palpate flank area: The flank area may be relevant for kidney assessment, but for a suprapubic catheter, the primary focus should be on the catheter insertion site and its function.

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The nurse is caring for a client who had surgery 1 day ago and is receiving a continuous infusion of fentanyl through an epidural catheter. Which intervention should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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