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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Clarify end of life desires: While understanding a client’s goals is vital, this may not address her immediate needs. The client is already showing signs of distress and hypoxia, so initiating comfort measures promptly is more urgent than discussing future preferences.

B. Offer sips of favorite beverages: Offering fluids may help with oral comfort but does not address the client’s respiratory distress or overall suffering. It is a low-priority intervention in the setting of acute hypoxia and confusion related to terminal illness.

C. Initiate comfort measures: Comfort measures are the priority for a terminally ill client with hypoxia and confusion who is refusing food and expressing a wish to go home. This aligns care with the client's likely stage in the dying process and ensures symptom relief over aggressive interventions.

D. Prepare for emergent oral intubation: Intubation is invasive and likely inconsistent with palliative goals in end-stage cancer. Without clear patient consent or indication that life-prolonging measures are desired, focusing on comfort is more appropriate and ethical.

A. Encourage the parent to apply lotion with each diaper change. B. Instruct the parent to change the child's diaper more often. C. Ask the parent to decrease the infant's intake of fruits for 24 hours. D. Tell the parent to cleanse with soap and water at each diaper change.

Correct Answer is B

Explanation

A. Encourage the parent to apply lotion with each diaper change: Lotions are not usually recommended for diaper rash as they can trap moisture against the skin, worsening irritation. Barrier creams (like zinc oxide) are preferred.

B. Instruct the parent to change the child's diaper more often: Frequent diaper changes help keep the area dry and clean, reducing skin irritation and promoting healing, especially when there's no sign of infection or allergy.

C. Ask the parent to decrease the infant's intake of fruits for 24 hours: There’s no indication that diet is contributing to the rash, especially since there are no watery stools or other signs of gastrointestinal upset.

D. Tell the parent to cleanse with soap and water at each diaper change: Using soap can dry or irritate already sensitive skin. Plain water or gentle wipes without alcohol/fragrance are preferred for cleaning the area.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Correct Answer is B

Explanation

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