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?
Hypertension.
Tachypnea.
Tachycardia.
Fever.
The Correct Answer is D
Choice A rationale
Hypertension is not a common adverse effect of epidural anesthesia. In fact, epidurals can cause hypotension due to the blockade of sympathetic nerves.
Choice B rationale
Tachypnea is not typically associated with epidural anesthesia. Common side effects include low blood pressure and headache.
Choice C rationale
Tachycardia is not a common adverse effect of epidural anesthesia. More common side effects include low blood pressure and urinary retention.
Choice D rationale
Fever is a known adverse effect of epidural anesthesia. It can occur due to the body’s response to the epidural procedure.
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Correct Answer is C
Explanation
Choice A rationale
Administering NSAIDs every 4 to 6 hours is not a primary measure to prevent thrombophlebitis. NSAIDs are used for pain relief and inflammation reduction, but they do not directly prevent blood clots.
Choice B rationale
Applying elastic stockings before the client gets out of bed can help prevent blood clots by promoting blood flow in the legs. However, this measure alone is not sufficient to prevent thrombophlebitis.
Choice C rationale
Ambulation, or walking, is one of the most effective measures to prevent thrombophlebitis. It promotes circulation and prevents blood from pooling in the legs, reducing the risk of clot formation.
Choice D rationale
Applying warm, moist packs to the client’s lower legs can help relieve pain and inflammation but does not directly prevent thrombophlebitis. This measure is more supportive rather than preventive.
Correct Answer is C
Explanation
Choice A rationale
Assessing the client’s socioeconomic status is important for understanding their overall health and access to resources, but it is not directly related to providing information about contraception.
Choice B rationale
Selecting the best method of contraception for the client is not the nurse’s role. The decision should be made by the client based on their individual preferences and health considerations.
Choice C rationale
Performing unbiased teaching is essential for providing accurate and comprehensive information about available methods of contraception. The nurse should present all options without imposing personal beliefs or preferences.
Choice D rationale
Providing information on all available methods is important, but it should be done in an unbiased manner. The nurse should ensure that the client has all the necessary information to make an informed decision.