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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- Administering medication into the deltoid muscle is not typically done in newborns. Phytonadione is given intramuscularly, usually in the vastus lateralis muscle, not the deltoid muscle.
B) Incorrect- Phytonadione should be given within 1 hour of birth, not 12 hours after birth. Delaying the administration increases the risk of bleeding complications.
C) Correct- The size of the needle is important for the newborn's comfort, A 25-gauge needle is the appropriate size for administering phytonadione to a newborn. A smaller needle may not deliver the medication adequately, and a larger needle may cause more tissue damage and bleeding.
D) Incorrect- The mother's Rh factor is irrelevant for the administration of phytonadione.
Rh factor affects the risk of hemolytic disease in the newborn, which is a different condition from hemorrhagic disease.
Correct Answer is C
Explanation
A) Incorrect- Applying ointment to the skin during phototherapy is typically avoided as it can interfere with the effectiveness of the therapy.
B) Incorrect- Giving distilled water after feedings is not a typical intervention for phototherapy.
C) Correct - Repositioning the newborn every 2 to 3 hours is important to ensure adequate exposure of the skin to the phototherapy lights and to prevent pressure points.
D) Incorrect- Monitoring blood glucose levels is not a standard intervention during phototherapy unless there are specific indications for doing so.
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