When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Low intermittent suction prescribed for the nasogastric tube is turned off.

A Hemovac drain is partially full of serous drainage and is not compressed.

The urinary catheter drainage bag is almost completely full of amber urine.

Oxygen is being administered via nasal cannula at 4 L/minute without humidification.

Answer and Explanation

The Correct Answer is D

A. This requires prompt attention but is not immediately life-threatening.

B.   This requires attention but does not pose an immediate threat to the client's condition.

C.   An almost completely full urinary catheter drainage bag requires attention but does not pose an immediate threat to the client's condition.
D.   Administering oxygen without humidification could lead to mucosal dryness and damage, and should be addressed promptly.

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Correct Answer is {"dropdown-group-1":"A"}

Explanation

Epidural anesthesia, commonly used for pain relief during labor, works by blocking nerve impulses in the lower part of the spine, leading to a decrease in sensation and pain in that area. However, this blockade also affects the sympathetic nerves, which are responsible for regulating blood pressure. When these nerves are blocked, they can cause peripheral vasodilation, which is the widening of the blood vessels in the periphery of the body.

Peripheral vasodilation leads to a decrease in vascular resistance, which can significantly lower blood pressure. This drop in blood pressure, known as hypotension, is a common side effect of epidural anesthesia. Hypotension can reduce the blood flow to vital organs, including the placenta, which may affect fetal oxygenation if not promptly and effectively managed. This necessitates careful monitoring and management, typically involving fluid administration and sometimes the use of medications to maintain stable blood pressure during the administration of epidural anesthesia.

A. Activated partial thromboplastin time (aPTT) is 2 times the control value. B. S3 heart sounds are present with auscultation. C. Cardiac tracing shows 1.2 mm wide Q waves half the height of the complex. D. Guaiac test of the stools is positive.

Correct Answer is A

Explanation

A. An aPTT that is 2 times the control value indicates that the heparin is effectively anticoagulating the blood, which is a desired outcome in managing MI to prevent clot formation.
B. S3 heart sounds can indicate heart failure and are not a sign of a satisfactory response to MI treatment.
C. Wide Q waves indicate a previous infarction but do not reflect the immediate effectiveness of the treatment.
D. A positive guaiac test indicates gastrointestinal bleeding, which is a potential complication rather than a satisfactory response.

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When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and orders. Drag from Word Choices to complete the sentence. The client receiving epidural anesthesia would be at risk for developingdue to

Correct Answer is {"dropdown-group-1":"A"}

Explanation

A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?

Correct Answer is A

Explanation

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