A nurse is caring for a client who is returning to the medical-surgical unit following a procedure that required spinal anesthesia. Which of the following findings should indicate to the nurse the client is experiencing a complication related to the anesthesia?

No urge to void

Numbness in legs

Headache

Hiccups

Answer and Explanation

The Correct Answer is C

A. A lack of urge to void can be a temporary side effect of spinal anesthesia but is not necessarily a sign of a complication.

B. Numbness in the legs is an expected and temporary effect of spinal anesthesia and should resolve as the anesthesia wears off.

C. A headache, particularly a post-dural puncture headache, can be a complication of spinal anesthesia caused by a leak of cerebrospinal fluid at the puncture site.

D. Hiccups are generally unrelated to spinal anesthesia and are not a common complication.

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Correct Answer is B

Explanation

A. The incentive spirometer should typically be used more frequently, often every 1-2 hours while awake, rather than every 4 hours.

B. Inhaling deeply and holding the breath for a few seconds (often 5-10) is a common recommendation for effective use of the incentive spirometer to maximize lung expansion.

C. The client should be in a sitting position or at a 45-degree angle for optimal use, not just 30 degrees.

D. The recommended breath hold time is usually around 5-10 seconds, not 7 seconds, depending on the specific guidelines provided by the healthcare team.

A. Use sterile gloves to place gentle pressure on the exposed organs. B. Have the client lie supine with legs straight. C. Cover the area with saline-soaked sterile dressings. D. Gently suction secretions from the wound bed using a 12 gauge sterile catheter.

Correct Answer is C

Explanation

A. Placing pressure on exposed organs is not appropriate and could cause further damage.

B. Having the client lie supine with legs straight could increase tension on the abdominal wound and exacerbate the evisceration.

C. Covering the eviscerated organs with saline-soaked sterile dressings is the correct intervention to protect the organs from infection and prevent them from drying out while waiting for emergency surgical intervention.

D. Suctioning secretions from the wound bed is not appropriate and could cause additional trauma to the exposed organs.

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A nurse is caring for a client who is returning to the medical-surgical unit following a procedure that required spinal anesthesia. Which of the following findings should indicate to the nurse the client is experiencing a complication related to the anesthesia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about how to use an incentive spirometer with a client. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds an evisceration. Which of the following interventions is appropriate?

Correct Answer is C

Explanation

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