Nokea
The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension,the nurse should:
- A. Place her in Trendelenburg position
- B. Decrease the rate of the IV infusion
- C. Administer oxygen via nasal cannula
- D. Increase the rate of the IV infusion
Correct Answer: D
Rationale: Hypotension from epidural anesthesia results from vasodilation. Increasing the IV infusion rate (e.g. with saline) restores blood volume and pressure. Trendelenburg may worsen spinal anesthesia spread and oxygen is secondary unless hypoxia occurs.
You may also like to solve these questions
The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort decreases when he:
- A. Avoids eating
- B. Rests in a recumbent position
- C. Eats a meal or snack
- D. Sits upright after eating
Correct Answer: C
Rationale: Duodenal ulcers cause pain relieved by eating due to buffering of gastric acid. Pain worsens when the stomach is empty. Resting or sitting upright does not directly relieve symptoms.
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4'' and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
- A. Obtain an accurate weight
- B. Search the client's purse for pills
- C. Assess vital signs
- D. Assign her to a room with someone her own age
Correct Answer: C
Rationale: Vital signs are a high priority when working with self-destructive clients.
A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
- A. Explain that he will be kept NPO for 24 hours before the exam
- B. Practice with him so he will be able to hold his breath for 1 minute
- C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver
- D. Explain that his vital signs will be checked frequently after the test
Correct Answer: D
Rationale: Post-liver biopsy, vital signs are monitored frequently to detect hemorrhage or shock, the most likely complications.
A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?
- A. Hold the child's discharge for 1 hour.
- B. Notify the physician immediately.
- C. Discharge the child as the physician ordered.
- D. Administer an antiemetic as necessary.
Correct Answer: B
Rationale: Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The physician should be notified immediately so that a serum theophylline level can be ordered.
A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse's knowledge of the anatomy of the respiratory system in pediatric clients?
- A. The diameter of the trachea is much smaller in children than in adults.
- B. The tongue is proportionally smaller in children than in adults.
- C. The pediatric airway is more rigid than that of the adults.
- D. The length of the pediatric airway is longer in children than in adults.
Correct Answer: A
Rationale: The airway in children is much smaller than it is in adults. The diameter of the trachea in the newborn is 4 mm and that of the adult is 20 mm. A small change in the diameter of the airway can make a major difference in the pediatric client. The tongue is proportionally larger in children and fills most of the oral cavity, thereby decreasing air space. The entire pediatric airway is elastic. Elasticity diminishes with age, however. The distances between respiratory structures are shorter than that of adults, and therefore organisms are able to move more rapidly down the throat, leading to more extensive respiratory involvement.