A nurse is caring for a patient in the immediate postoperative period after surgery in which a spinal anesthetic was used
The patient has not voided and complains of headache. The patient has a pulse of 62 beats per minute, a respiratory rate of 16 breaths per minute, and a blood pressure of 92/48 mm Hg. Which action by the nurse is appropriate?
a. Contact the anesthetist to request an order for ephedrine.
b. Have the patient sit up to relieve the headache pain.
c. Lower the head of the bed to a 10- to 15-degree head-down position.
d. Obtain an order for a urinary catheter for urinary retention.
ANS: C
Spinal anesthetics have several adverse effects, but the most significant is hypotension caused by the venous dilation that occurs from blockade of sympathetic nerves. The result is decreased blood return to the heart, which causes reduced cardiac output and a drop in blood pressure. The first step in treating this is to put the patient in a 10- to 15-degree head-down position to promote venous return to the heart. Ephedrine or phenylephrine is used if the first measure fails. Spinal headaches are common; the intervention for this is to have the patient assume a supine position. Urinary retention can occur secondary to autonomic blockade; it is a concern if the patient has not voided for 8 hours after the procedure, but not in the immediate postoperative period.
You might also like to view...
The nurse explains to the nursing student that lactose is hydrolyzed into glucose and galactose in which organ?
A. Gallbladder B. Large intestine C. Small intestine D. Stomach
The nurse is preparing to administer some iron drops to a toddler. Which factor can increase iron absorption? (Select all that apply.)
a. Vitamin A b. Acidity (low pH) c. Phosphates (milk) d. Malabsorptive disorders e. Ascorbic acid (Vitamin C)
Which nursing interventions should the nurse implement when administering oral potassium chloride (KCl)?Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
A. Instruct the client to sit straight up to swallow the pill. B. Crush the tablet and put it in a soft food. C. Instruct the client to chew the tablet. D. Administer the prescription with an antacid. E. Instruct the client to take the prescription prior to eating a meal.
When assessing the child with osteogenesis imperfecta, the nurse should expect to observe:
a. Discolored teeth. c. Increased muscle tone. b. Below-normal intelligence. d. Above-average stature.