Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?

Absence of the client's gag reflex

The client has a respiratory rate of eight (8)

Loss of sensation at the 5th lumbar space

The blood pressure is within 20% of the client's baseline

Answer and Explanation

The Correct Answer is B

A. Absence of the client's gag reflex: This finding is not typically related to spinal anesthesia complications. The gag reflex is more pertinent to general anesthesia and its effects on the brainstem.
B. The client has a respiratory rate of eight (8): This is the correct choice. A low respiratory rate (bradypnea) could indicate significant complications from spinal anesthesia, such as respiratory depression, especially if the anesthesia affects the muscles involved in respiration.
C. Loss of sensation at the 5th lumbar space: This could be a normal effect of spinal anesthesia if the level of anesthesia was intended to cover this area, but it does not necessarily indicate a complication.
D. The blood pressure is within 20% of the client's baseline: A slight change in blood pressure within this range is generally not considered a severe complication of spinal anesthesia. Significant hypotension or instability would be more concerning.

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

Explanation

A. Muscle cramps: Muscle cramps can occur due to electrolyte imbalances, such as low potassium, which are common in states of dehydration and fluid imbalance.
B. Bradycardia: Bradycardia is not typically associated with dehydration or fluid imbalance. Dehydration usually causes an increase in heart rate (tachycardia) as the body tries to maintain adequate circulation.
C. Concentrated urine: Concentrated urine is a common sign of dehydration as the kidneys conserve water, leading to reduced urine output and higher urine concentration.
D. Tachycardia: Tachycardia is a compensatory mechanism in response to decreased fluid volume, as the heart pumps faster to maintain adequate blood flow and blood pressure.
E. Increased thirst: Increased thirst is a natural response to dehydration as the body signals the need for more fluid intake to correct the fluid imbalance.

A. Discard the container of formula every 12 hours B. Irrigate the tube with sterile water before administering medications C. Measure & record the residual volume after each feeding D. Keep head of bed elevated 30 degrees

Correct Answer is D

Explanation

A. Discard the container of formula every 12 hours: While this is important for preventing contamination, it does not directly address the risk of aspiration.
B. Irrigate the tube with sterile water before administering medications: This helps maintain tube patency and prevent clogging but does not significantly impact the prevention of aspiration.
C. Measure & record the residual volume after each feeding: Monitoring residuals is crucial for assessing gastric emptying and preventing overfeeding but does not directly prevent aspiration.
D. Keep head of bed elevated 30 degrees: This is the correct choice. Elevating the head of the bed reduces the risk of aspiration by ensuring that gravity helps keep the feeding in the stomach and minimizes the risk of reflux into the esophagus.

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Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?

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Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is caring for a client receiving continuous enteral feedings via a gastrostomy tube. Which nursing intervention is most important to help prevent aspiration?

Correct Answer is D

Explanation

To promote effective coughing, deep breathing, and ambulation in the postoperative client, what nursing action is most important?

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