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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Bring a sterile chest drainage unit from central supply to the unit: This task can be delegated to a UAP. It involves retrieving an item from central supply, which is a non-clinical task and does not require nursing judgment or clinical assessment.
B. Observe a client's gait to determine the need for assistance: While UAPs can observe and report changes, assessing gait for the need of assistance involves clinical judgment and evaluation of the patient's safety, which should be done by a nurse.
C. Evaluate a client's urinary catheter for proper drainage: Evaluating proper drainage involves clinical assessment, which is within the scope of nursing practice, not a task for a UAP. The nurse should assess for proper functioning and any signs of complications.
D. Call the pharmacy to obtain a client's next antibiotic dose: Calling the pharmacy for medications involves communication and clinical decision-making, which is outside the scope of tasks that can be delegated to a UAP. The nurse should handle medication orders.
Correct Answer is ["B","C","D"]
Explanation
A. "Hyperglycemia often results in weight loss." While chronic uncontrolled hyperglycemia, particularly in Type 1 diabetes, can lead to weight loss due to the body breaking down fat and muscle for energy, this is less typical for the acute or early signs of hyperglycemia.
B. "Hyperglycemia often presents as increased thirst and urination." This is a classic symptom of hyperglycemia, polydipsia (increased thirst) and polyuria (increased urination), caused by the body attempting to eliminate excess glucose through urine.
C. "Hyperglycemia causes an increased sensation of being hungry." Hyperglycemia can cause an increased sensation of hunger (polyphagia), which occurs due to insulin resistance or the body’s inability to use glucose properly.
D. "Hyperglycemia causes a headache and flushed, dry skin." A common symptom of hyperglycemia is headache, and flushed, dry skin can occur due to dehydration from excessive urination.
E. "Hyperglycemia causes cool and clammy skin." Cool and clammy skin is more indicative of hypoglycemia (low blood sugar) rather than hyperglycemia. Hyperglycemia usually presents with warm, dry skin due to dehydration.
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