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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Positioning the head of the patient’s bed flat is not typically recommended after a laryngectomy. Instead, the head of the bed is often elevated to help reduce swelling and improve breathing.
Choice B rationale
Providing the patient with humidified air can help keep the airway moist and reduce discomfort, making it a common practice after a laryngectomy.
Choice C rationale
While keeping the surgical site clean is important, cleaning the patient’s sutures every 8 hours is not a standard recommendation and may vary based on the surgeon’s instructions.
Choice D rationale
Suctioning the patient’s mouth on the side of the surgery is not typically recommended as it could potentially disrupt the surgical site.
Correct Answer is D
Explanation
Choice A rationale
Glucocorticoid medications are not typically used in the treatment of diabetic ketoacidosis (DKA). These medications can actually increase blood glucose levels, which would not be beneficial in a situation where blood glucose is already significantly elevated.
Choice B rationale
Dextrose 5% in 0.45% sodium chloride is not typically used in the initial treatment of DKA. This solution contains glucose, which would add to the already high blood glucose levels in DKA5.
Choice C rationale
Oral hypoglycemic medications are not typically used in the treatment of DKA. These medications are generally used in the management of type 2 diabetes. In DKA, which is more common in type 1 diabetes, insulin is usually required to lower blood glucose levels.
Choice D rationale
A 0.9% sodium chloride IV bolus is often part of the initial treatment for DKA. This helps to replace the fluid lost through excessive urination, a common symptom of DKA5.
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