Nokea
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hyperglycemia
- B. Bilateral crackles
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: Correct Answer: C - Hypotension
Rationale: Opioid analgesics can cause vasodilation leading to hypotension due to decreased systemic vascular resistance. The nurse should monitor the client for signs of hypotension such as lightheadedness, dizziness, and decreased blood pressure. Monitoring for hypotension is crucial to prevent complications like decreased perfusion to vital organs.
Summary:
A: Hyperglycemia - Opioid analgesics do not typically cause hyperglycemia.
B: Bilateral crackles - This finding is more indicative of fluid overload or heart failure, not a direct effect of opioid analgesics.
D: Polyuria - Opioid analgesics do not usually cause polyuria; in fact, they can cause urinary retention as a side effect due to bladder sphincter relaxation.
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Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Coombs test result
- B. Mucous membrane assessment
- C. Intake and output
- D. Respiratory rate
- E. Head assessment finding
- F. Heart rate
- G. Sclera color
Correct Answer: A,B,C,G
Rationale: The correct answers are A, B, C, and G. A Coombs test result should be reported as it indicates the presence of antibodies that can cause hemolytic anemia. Mucous membrane assessment is crucial for detecting hydration status and oxygenation. Intake and output monitoring helps assess kidney function and fluid balance. Sclera color can indicate liver function or jaundice. Choices D, E, and F are not necessarily critical findings to report urgently to the provider in most cases. Monitoring respiratory rate, heart rate, and head assessment findings are important but may not require immediate provider notification unless there are significant abnormalities.
A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?
- A. The Plastibell will be removed 4 hours after the procedure.
- B. Make sure the newborn’s diaper is snug.
- C. Yellow exudate will form at the surgical site in 24 hours.
- D. Notify the provider if the end of your baby’s penis appears dark red.
Correct Answer: D
Rationale: The correct answer is D: Notify the provider if the end of your baby’s penis appears dark red. This is important because it could indicate infection or other complications. Dark red color may suggest poor blood flow or infection, requiring immediate medical attention to prevent further complications.
Incorrect answers:
A: The Plastibell is not typically removed after 4 hours, as it usually falls off on its own within a week.
B: Snug diaper can cause discomfort and hinder proper healing.
C: Yellow exudate forming at the site in 24 hours is normal as part of the healing process.
Therefore, option D is the most critical information for the parents to be aware of.
A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
- A. Turn the client to a side-lying position.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Massage the client’s fundus.
- D. Assist the client to empty their bladder.
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This action helps improve venous return to the heart, which can increase blood pressure. Placing the client on their side can prevent compression of the vena cava by the uterus, reducing hypotension. Options B and D are not directly related to managing hypotension. Option C is incorrect as massaging the fundus is typically done postpartum to prevent hemorrhage.
A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
- A. Epigastric discomfort
- B. Flank pain
- C. Temperature 37.7°C (99.8°F)
- D. Abdominal cramping
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is an infection of the kidneys, commonly seen in pregnant women due to physiological changes. Flank pain is a classic symptom due to inflammation of the kidney tissue. Epigastric discomfort (A) is more indicative of gastrointestinal issues, not typically associated with pyelonephritis. Temperature elevation (C) is a common sign of infection but not specific to pyelonephritis. Abdominal cramping (D) is more commonly associated with uterine contractions in pregnancy.
A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.
- A. Instruct the client to empty their bladder.
- B. Position the client supine with knees flexed and place a small, rolled towel under one of their hips.
- C. Palpate the fetal part positioned in the fundus.
- D. Palpate the fetal parts along both sides of the uterus.
Correct Answer: A, B, C, D
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
The correct sequence of actions for performing Leopold maneuvers includes:
A) Instruct the client to empty their bladder to enhance visualization and palpation accuracy.
B) Position the client supine with knees flexed to provide access and comfort for the client during the procedure.
C) Palpate the fetal part positioned in the fundus to determine the baby's presentation and position.
D) Palpate the fetal parts along both sides of the uterus to assess the location and movement of the fetus.
It is important to follow these steps to accurately assess the fetal position and presentation. Other choices are incorrect as they do not align with the standard procedure for Leopold maneuvers.