A nurse is caring for a client who is receiving controlled epidural analgesia infusion. Which of the following nursing actions is appropriate?
Cleansing the insertion site daily.
Covering the insertion site with a transparent dressing.
Administering supplemental opioids as needed.
Replacing the infusion tubing every 72 hr.
The Correct Answer is B
Choice A reason: Cleansing the insertion site daily is not appropriate because frequent manipulation increases the risk of introducing pathogens into the epidural space. The site should be maintained with sterile technique and minimal disturbance to reduce infection risk.
Choice B reason: Covering the insertion site with a transparent dressing is appropriate because it allows continuous visualization of the site for signs of infection or leakage while maintaining sterility. Transparent dressings also reduce the need for frequent manipulation, thereby lowering infection risk.
Choice C reason: Administering supplemental opioids without provider orders is unsafe. Epidural analgesia is tightly regulated, and additional opioids could increase the risk of respiratory depression, sedation, and overdose.
Choice D reason: Replacing infusion tubing every 72 hours is standard for IV therapy but not specific to epidural analgesia. Epidural tubing requires specialized sterile handling and should not be routinely changed unless clinically indicated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Survivors of prostate cancer are not the primary at-risk group for testicular cancer. Testicular cancer typically affects younger men, not those with prostate cancer.
Choice B reason: Benign prostatic hypertrophy occurs in older men and is unrelated to testicular cancer risk. Education for this group would not target the correct population.
Choice C reason: Older adults are not at increased risk for testicular cancer. This cancer most commonly affects men between ages 15–35, so pamphlets at a health fair for older adults would miss the target population.
Choice D reason: Young adults are the highest-risk group for testicular cancer. An information booth at a community resource fair for young adults would effectively reach the population most at risk, making this the correct answer.
Correct Answer is D
Explanation
Choice A reason: Irrigating the tube with 10 mL of cool water every 6 hr is incorrect. Tubes are flushed with warm water, typically before and after feedings or medication administration, not routinely every 6 hours with cool water. Cool water can cause discomfort and is not recommended.
Choice B reason: Elevating the head of the bed to only 15° is insufficient to prevent aspiration. The recommended elevation is at least 30° to 45° during feedings to reduce the risk of reflux and aspiration pneumonia.
Choice C reason: Replacing the feeding bag every 72 hours is unsafe. Feeding bags should be replaced every 24 hours to prevent bacterial contamination and infection. Extending use to 72 hours increases infection risk.
Choice D reason: Checking gastric residual every 4 hours is the correct answer because it ensures the client is tolerating the feeding and prevents complications such as aspiration or delayed gastric emptying. Monitoring residuals helps guide feeding adjustments and promotes safety.
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