Which nursing diagnosis has the highest priority for the client who is receiving epidural analgesia with fentanyl (Sublimaze) for acute postoperative pain?
A. Risk for Respiratory Depression related to opioid administration
B. Risk for Impaired Skin Integrity related to immobility
C. Risk for Infection related to epidural catheter location
D. Risk for Confusion related to opioid administration
C
Use of an epidural catheter allows the epidural space around the spinal cord to become contami-nated. Contamination can enter through the catheter or around the catheter, leading to meningitis or encephalitis. Clients with epidural catheters can get out of bed and walk, so immobility is not a problem. Respiratory depression is rare when fentanyl is being used, and confusion is not a complication of epidural anesthesia because the drug does not reach the CNS.
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The marketing department of a major children's hospital is hosting a fund-raiser for the local Ronald McDonald House. In the past, fund-raisers were successful when scheduled in the spring
This year, the fund-raiser is scheduled in the fall, when the city and several local organizations have community festivals. The first fund-raiser was scheduled 10 years ago in the fall and raised $50,000, only one eighth of the goal. This depicts an example of which of the following deci-sion-making distortions? a. Confirming evidence trap b. Estimating and forecasting trap c. Status quo trap d. Sunk cost trap
A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?
a. Schedule a sweat chloride test. b. Arrange for a hospice nurse visit. c. Place the patient on a low-sodium diet. d. Perform chest physiotherapy every 4 hours.
Two months later, the teen returns with no noticeable improvement. The acne is now causing the teen extreme distress because of the impact on her appearance. The physician prescribes Accutane. The teen is 16 years old
How will this affect the patient education the teen will need? a. Accutane has a strong odor, so the teen may not comply with treatment b. Accutane has few side effects, so little education is needed c. Accutane will harm a developing fetus, so contraception will be needed if the teen is sexually active d. Female patients cannot take Accutane, so there will not be any need to educate this teen on a drug that she will not take
A patient's spouse, who is a chemist, asks a nurse how serotonin reuptake inhibitors (SSRIs) lift depression. The nurse should explain that SSRIs:
a. destroy increased amounts of neurotransmitters. b. make more serotonin available at the synaptic gap. c. increase production of acetylcholine and dopamine. d. block muscarinic and alpha1-norepinephrine receptors.