A laboring patient has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, the nurse would expect to do which of the following?
1. Observe fetal heart rate variability.
2. Rapidly infuse 500–1,000 ml of intravenous fluids.
3. Place the patient in the semi-Fowler's position.
4. Teach the patient appropriate breathing techniques.
Correct Answer: 2
Rationale: Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common side effect of an epidural.
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A patient has sustained a head injury in a motor vehicle accident. He has nitroglycerine tablets for chest pain and asks the nurse for one due to chest pain. What effect will the nitroglycerine have on the patient's current status?
A) Nitroglycerine will raise the patient's blood pressure. B) Nitroglycerine will cause decreased cerebral edema. C) Nitroglycerine will increase intracranial pressure. D) Nitroglycerine will decrease blood glucose.
The nurse is caring for a client who has been admitted with persistent diarrhea lasting 3 days. Which are appropriate nursing diagnoses for this client during the acute phase of the illness?
Select all that apply. A) Decreased Cardiac Output B) Ineffective Airway Clearance C) Deficient Fluid Volume D) Knowledge Deficit E) Risk for Injury
The nurse is caring for a 3-year-old boy. The parents are concerned that he is exhibiting signs of cognitive delays. Which of the following statements by the parents would indicate autism spectrum disorder rather than possible mental retardation?
A) "He is not speaking in complete sentences." B) "We can understand a lot of what he says, but no one else can." C) "He seems to be speaking less and less." D) "He is unable to sit still for a short story."
The nurse recognizes the staging T3, N2, M2 of the patient's cancer. Which interpretation is correct?
a. Small tumor with fewer than two lymph nodes involved. b. Large tumor that is localized. c. Small tumor with adjacent nodes involved. d. Large tumor with extensive lymph node involvement.