A nurse is assessing a client who is in active labor and just received an epidural. Which of the following findings should the nurse document as an adverse effect?

Tachypnea

Hyperreflexia

Hypothermia

Hypotension

Answer and Explanation

The Correct Answer is D

Rationale:

A. Tachypnea: An increased respiratory rate is not commonly associated with epidural anesthesia and is not a typical adverse effect. It may result from anxiety or pain but does not directly indicate a problem with the epidural.

B. Hyperreflexia: Epidurals often reduce sensation and reflexes, not heighten them. Hyperreflexia is not expected and would not be a direct adverse effect of epidural administration during labor.

C. Hypothermia: While mild temperature changes may occur, hypothermia is not a common or significant adverse effect of epidural anesthesia. It is not typically monitored as a key complication.

D. Hypotension: Epidural anesthesia can cause vasodilation by blocking sympathetic nerve fibers, leading to a drop in maternal blood pressure. This is a well-known and common adverse effect requiring close monitoring and potential intervention.

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Correct Answer is B

Explanation

Rationale:

A. Disconnecting the catheter from the drainage bag to empty the bag: This increases the risk of introducing pathogens into the closed urinary drainage system, leading to potential catheter-associated urinary tract infections (CAUTIs). The drainage bag should be emptied without breaking the system.

B. Emptying the drainage bag when it is half full: This prevents backflow of urine, which could lead to infection or increased bladder pressure. Regular emptying also allows for accurate measurement of urine output and maintains client comfort.

C. Keeping the drainage bag above waist level: Elevating the bag above the bladder increases the risk of backflow of urine into the bladder, which can introduce bacteria and cause infection. The bag should always remain below the level of the bladder.

D. Using sterile gloves when emptying the drainage bag: Sterile gloves are not necessary for this procedure. Clean gloves are sufficient since the nurse or AP is not entering the sterile parts of the urinary system but rather emptying the bag from the outlet port.

A. "I will remove gluten from my diet.” B. "I will remove peanuts from my diet.” C. "I will remove bananas from my diet. D. "I will remove dairy products from my diet."

Correct Answer is C

Explanation

Rationale:

A. "I will remove gluten from my diet.": Gluten is unrelated to latex allergies. It is typically avoided in conditions like celiac disease, but does not cross-react with latex proteins and is not a concern for latex-sensitive individuals.

B. "I will remove peanuts from my diet.": Although peanut allergies are common, there is no significant cross-reactivity between peanuts and latex. Avoiding peanuts is not necessary unless the client has a separate peanut allergy.

C. "I will remove bananas from my diet.": Bananas contain proteins similar to those found in natural latex. Clients with latex allergies often have cross-reactive food allergies, especially to bananas, avocados, kiwis, and chestnuts this is known as latex-fruit syndrome.

D. "I will remove dairy products from my diet.": Dairy products are not associated with latex sensitivity. Removing them offers no protective benefit for clients with a latex allergy unless a separate dairy intolerance or allergy exists.

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Finding	Nursing Intervention
Client's restlessness	dropdown
Client's behavior towards staff	dropdown
Client's hygiene	dropdown

A nurse is assessing a client who is in active labor and just received an epidural. Which of the following findings should the nurse document as an adverse effect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is supervising an assistive personnel (AP) who is caring for a client with an indwelling urinary catheter. Which of the following actions taken by the AP indicates proper technique?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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