A nurse is assisting with the care of a client who is receiving epidural anesthesia for pain management during labor. Which of the following actions should the nurse take?
Remind the client to void every 4 hr.
Encourage the client to alternate from side to side every 2 hr.
Raise the four side rails on the client's bed.
Monitor the client's blood pressure.
The Correct Answer is D
Choice A reason:
The nurse should not remind the client to void every 4 hours because epidural anesthesia can cause temporary loss of bladder sensation, making it difficult for the client to know when to void. Instead, the nurse should use a bladder scanner to assess for urinary retention and encourage the client to void regularly.
Choice B reason:
Encouraging the client to alternate from side to side every 2 hours is not directly related to the administration of epidural anesthesia. This action is commonly advised for clients who are on bed rest to prevent pressure ulcers and promote circulation. However, it is not specifically necessary for the client receiving epidural anesthesia for pain management during labor.
Choice C reason:
Raising the four side rails on the client's bed is not necessary in this situation. The use of side rails should be based on the client's mobility and risk assessment for falls. If the client is receiving epidural anesthesia, they may experience reduced mobility, but the decision to use side rails should be made on an individual basis, not solely based on the anesthesia.
Choice D reason:
Monitoring the client's blood pressure is a crucial action when a client is receiving epidural anesthesia. Epidural anesthesia can cause a drop in blood pressure, leading to hypotension. By regularly monitoring the client's blood pressure, the nurse can detect any significant changes and take appropriate actions to maintain hemodynamic stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C reason: The correct answer is choice C, "I need to use my levalbuterol inhaler before I exercise.” This statement indicates an understanding of the teaching because using the levalbuterol inhaler before exercise is a preventive measure for asthma symptoms. Levalbuterol is a short-acting beta-agonist that helps to relax the airway muscles and improve breathing. By using it before exercise, the client can prevent exercise-induced bronchoconstriction and reduce the risk of asthma symptoms during physical activity.
Choice A reason:
The statement "I will wait 15 seconds between puffs when using my levalbuterol inhaler” is incorrect. The recommended wait time between puffs of a levalbuterol inhaler is typically 30- 60 seconds to allow the medication to be fully absorbed and work effectively. Waiting only 15 seconds might not provide the desired therapeutic effect.
Choice B reason:
The statement "I need to use my fluticasone inhaler when I start to wheeze during exercise” is incorrect. Fluticasone is a corticosteroid inhaler used for long-term control of asthma symptoms, not for immediate relief during wheezing episodes. The client should use the fluticasone inhaler daily as prescribed to prevent asthma symptoms, including wheezing, from occurring in the first place.
Choice D reason:
The statement "I will stop using my fluticasone inhaler if I experience restlessness” is incorrect. Fluticasone is a long-term controller medication, and abruptly stopping it can lead to uncontrolled asthma symptoms and potentially exacerbate the condition. Restlessness might be a side effect of the medication, but it is not a reason to discontinue its use. If the client experiences any concerning side effects, they should consult their healthcare provider for appropriate management.
Correct Answer is D
Explanation
Choice A reason:
The client stating, "This test is to check if my baby has diabetes,” indicates a misunderstanding of the purpose of the 1-hr glucose tolerance test (GTT). The test is performed to screen for gestational diabetes in the mother, not to check the baby's diabetes status. Rationale: Gestational diabetes is a condition where high blood sugar levels develop during pregnancy, and it can affect both the mother and the baby's health.
Choice B reason:
The client mentioning, "If the result is higher than normal, I will need to be on insulin the rest of my life,” demonstrates a misconception about the implications of the 1-hr GTT. The 1-hr GTT is a preliminary screening test, and if the results are higher than normal, it indicates the need for further evaluation, but it does not immediately mean a lifetime dependence on insulin. Rationale: Insulin therapy may be required for managing gestational diabetes in some cases, but not necessarily for the rest of the mother's life.
Choice C reason:
The client saying, "If I forget and eat before the test, then I won't be able to have the test done,” indicates a misunderstanding of the test procedure. The 1-hr GTT requires fasting before the test, typically for 8 to 14 hours, to get accurate results. However, if the client mistakenly eats before the test, it doesn't mean they cannot have the test done at all; they may need to reschedule it after an appropriate fasting period. Rationale: Fasting is crucial for accurate glucose level measurement during the test.
Choice D reason:
The client stating, "If the results are high, then I need another test to see if I have gestational diabetes,” demonstrates a correct understanding of the 1-hr GTT. If the initial screening test shows elevated glucose levels, further testing, such as the 3-hour glucose tolerance test (GTT), is required to confirm the diagnosis of gestational diabetes. Rationale: The 3-hour GTT is a more comprehensive diagnostic test used to confirm or rule out gestational diabetes.
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