A nurse is collecting data from a client who is receiving epidural anesthesia. Which of the following findings indicates an adverse effect of this method of pain management?

Tachycardia

Fever

Tachypnea

Hypertension

Answer and Explanation

The Correct Answer is C

A)   Incorrect- Tachycardia (elevated heart rate) can be a common physiological response to pain or other factors and is not necessarily indicative of an adverse effect of epidural anesthesia.
B)   Incorrect- Fever might be related to various factors, including infection, and is not directly indicative of an adverse effect of epidural anesthesia.
C)   Correct - Tachypnea (rapid breathing) can be an adverse effect of epidural anesthesia.

It can indicate that the anesthesia has spread too high in the spinal column, potentially affecting the respiratory muscles and causing respiratory distress.
D) Incorrect- Hypertension might be a side effect of epidural anesthesia, but tachypnea is a more specific indication of an adverse effect in this context.

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Correct Answer is C

Explanation

A) Incorrect- Cleansing the perineum with povidone-iodine is not relevant to the collection process.
B) Incorrect- The 24-hour collection should start with the first-morning urination, not with any random urination.
C) Correct - Recording the time on the collection container for any missed urine specimens is important for accurate measurement.
D) Incorrect- Stool should not be added to the urine collection container, but this is not the most important point to emphasize in this teaching.

A. Umbilical area B. Suprapubic area C. Above the left iliac crest D. Below the liver border on the right abdomen

Correct Answer is C

Explanation

Rationale:

A) Incorrect - The umbilical area is not a typical location for auscultating fetal heart tones.
B) Incorrect - The suprapubic area is not a common location for auscultating fetal heart tones.
C) Correct - At 12 weeks of gestation, the nurse would typically auscultate the fetal heart tones above the left iliac crest, which is in the lower abdomen. This is where the uterus is located at this stage of pregnancy.
D) Incorrect - Auscultating below the liver border on the right abdomen is not a standard practice for fetal heart tone assessment.

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A nurse is collecting data from a client who is receiving epidural anesthesia. Which of the following findings indicates an adverse effect of this method of pain management?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has gestational hypertension about collecting a 24-hr urine specimen for protein. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is auscultating fetal heart tones with a Doppler device for a client who is at 12 weeks of gestation. Where should the nurse expect to auscultate the fetal heart tones?

Correct Answer is C

Explanation

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