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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Provide handouts written at a 12th grade reading level: Educational materials should be written at an appropriate reading level for the client, typically 6th to 8th grade for older adults, to promote understanding. Handouts at a 12th-grade level might be too complex.
B. Use background music to promote relaxation: While this could potentially help reduce anxiety for some people, it may also be distracting for others during important health teaching. The priority is clear and focused communication.
C. Turn on overhead lights while giving instructions: Proper lighting is essential, especially for older adults who may have visual impairments. Bright, direct lighting can help ensure the client clearly sees instructional materials and feels more comfortable during teaching.
D. Stand behind the client to avoid intimidation: Standing behind the client can be intimidating and might make the interaction feel less personal. It's important to engage the client in a way that encourages open communication, typically by sitting or standing at eye level.
Correct Answer is B
Explanation
A. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting:While antiemetics can be helpful, this action may not address the underlying issue of food smells causing nausea. It is important to address the client’s sensory triggers.
B. Encourage family members to cook meals outdoors and bring the cooked food inside:
This can help reduce the trigger for nausea caused by the smell of cooking food. Cooking outdoors minimizes exposure to food smells, which could alleviate the client’s discomfort.
C. Assess the client's mucous membranes and report the findings to the healthcare provider: Assessing the mucous membranes is important in general care, especially for clients with cancer, but it is not directly related to the reported issue of nausea triggered by food smells.
D. Advise the client to replace cooked foods with a variety of different nutritional supplements: While nutritional supplements can be useful if the client is unable to tolerate solid foods, this advice doesn't address the root cause of the nausea related to food smells.
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