A nurse is caring for a patient receiving epidural analgesia for pain during labor. Which of the following observations should be the nurse’s priority?
The patient’s blood pressure is 80/56 mm Hg.
The patient reports lower extremity weakness.
The patient’s temperature is 38.2°C (100.8 F).
The patient reports severe itching.
The Correct Answer is A
Choice A rationale
The patient’s blood pressure is significantly low, which could indicate hypotension, a serious side effect of epidural analgesia. This should be the nurse’s priority as it can lead to complications such as decreased perfusion to vital organs.
Choice B rationale
Lower extremity weakness can be a side effect of epidural analgesia, but it is not as immediately life-threatening as hypotension.
Choice C rationale
A slight increase in temperature may not be an immediate concern unless it continues to rise or is accompanied by other signs of infection.
Choice D rationale
Severe itching can be a side effect of epidural analgesia, but it is not as immediately life- threatening as hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Lubricating the suction catheter tip with sterile saline is not recommended because it can introduce bacteria into the tracheostomy tube and cause infection.
Choice B rationale
Hyperventilating the patient on 100% oxygen prior to suctioning is not necessary and can cause complications such as oxygen toxicity.
Choice C rationale
Performing chest physiotherapy prior to suctioning is not typically done during tracheostomy care. Chest physiotherapy is a separate procedure that involves physical techniques to remove mucus from the respiratory tract.
Choice D rationale
Suctioning two to three times with a 60-second pause between passes is the correct action. This helps to remove secretions effectively without causing hypoxia.
Correct Answer is ["A","C","D","E"]
Explanation
Smoking, Diabetes, Atherosclerosis, and Weak pedal pulses.
Factors that contribute to poor circulation to the limb include:
- Smoking: It can cause constriction and damage to the blood vessels, leading to poor circulation.
- Diabetes: High blood sugar levels can damage blood vessels and nerves, leading to poor circulation.
- Atherosclerosis: This is a condition where plaque builds up in the arteries, narrowing them and reducing blood flow.
- Weak pedal pulses: This can be a sign of reduced blood flow to the lower extremities. A sodium-restricted diet (Choice B) is not typically associated with poor circulation.
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