in some hip surgeries an epidural catheter for fentanyl epidural analgesia is given what is your nursing priority care in such a case
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Nursing Elites

ATI RN

Nutrition ATI Test

1. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

Correct answer: D

Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.

2. What is the name of the record that shows all medications and treatments provided on a repeated basis?

Correct answer: D

Rationale: The 'Medicine and Treatment Record' is the document that maintains a comprehensive log of all medications and treatments provided on a routine basis. It does not refer to the 'Discharge Summary', which is a clinical report prepared by healthcare professionals at the end of a hospital stay or series of treatments. The 'Nursing Health History and Assessment Worksheet' is used to gather comprehensive data about the patient's health history and current health status, but it does not record ongoing treatment details. The 'Nursing Kardex' is a patient care information system used to quickly communicate patient needs, but it does not consistently record all medications and treatments provided.

3. 24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?

Correct answer: A

Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.

4. What is a common symptom of vitamin D deficiency?

Correct answer: C

Rationale: The correct answer is C: Bone pain. Vitamin D deficiency often leads to bone pain and weakness as it plays a crucial role in maintaining bone health by aiding in the absorption of calcium. Hair loss (choice A) is not a common symptom of vitamin D deficiency. Night blindness (choice B) is typically associated with vitamin A deficiency, not vitamin D deficiency. Rashes (choice D) are not a common symptom of vitamin D deficiency.

5. What percentage of body weight as fat does a woman with a healthy body composition typically average?

Correct answer: C

Rationale: A healthy body fat percentage for women typically ranges between 21% and 33%, with 25% being an average healthy body fat percentage. Choice A (5%) is too low for a healthy body fat percentage and is more in line with essential body fat levels. Choice B (15%) is also lower than the typical range for a healthy body fat percentage. Choice D (35%) is too high and would be considered high body fat for women.

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