The nurse is caring for a client who had surgery 1 day ago and is receiving a continuous infusion of fentanyl through an epidural catheter. Which intervention should the nurse perform first?
Assess for signs of urine retention.
Inspect epidural catheter insertion site.
Monitor the client's dermatome level for sensation.
Inquire if the client is experiencing breakthrough pain.
The Correct Answer is C
A. Assess for signs of urine retention: While important, urinary retention is a later complication. It does not take priority over assessing for potentially serious effects like respiratory depression or excessive spread of anesthesia.
B. Inspect epidural catheter insertion site: Inspecting the site helps identify infection or dislodgement but is not the first priority. Neurological and respiratory assessments take precedence due to fentanyl’s CNS effects.
C. Monitor the client's dermatome level for sensation: This assesses the spread of the anesthetic, ensuring it hasn’t ascended to high thoracic levels, which could depress respiration. It’s the most urgent check for client safety.
D. Inquire if the client is experiencing breakthrough pain: Pain assessment is critical, but ensuring safe levels of sensory block must come first to rule out excessive anesthetic spread or complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.
B. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.
C. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.
D. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.
Correct Answer is C
Explanation
A. Type of anticonvulsant prescribed: While the class or type of anticonvulsant influences seizure control, it does not directly indicate whether the client is receiving a sufficient dosage. The therapeutic effectiveness depends more on blood concentration than classification.
B. History of a recent illness: Acute illness can temporarily lower the seizure threshold, but it is a less specific indicator for predicting recurrence than pharmacologic control. The underlying condition must be assessed, but medication levels are more predictive of seizure risk.
C. Therapeutic level of medication: A subtherapeutic drug level is a strong predictor of seizure recurrence. Maintaining an adequate plasma concentration ensures optimal seizure control and is crucial in clients recovering from status epilepticus, where precise management is essential.
D. Duration of previous seizure activity: The length of the prior seizure can indicate severity but not the likelihood of recurrence. Even brief seizures can recur if anticonvulsant levels are inadequate, so duration is not as clinically useful as drug level monitoring.
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