Nokea
A client with a lumbar spinal fusion is preparing for discharge. Which activity should the nurse advise the client to avoid?
- A. Walking short distances daily.
- B. Lifting objects heavier than 10 pounds.
- C. Sleeping on a firm mattress.
- D. Using a recliner for sitting.
Correct Answer: B
Rationale: Lifting heavy objects can strain the surgical site, delaying healing post-spinal fusion.
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Which symptom suggests worsening neurological status in a client with a head injury?
- A. Improved orientation.
- B. Decreased pulse rate.
- C. Stable blood pressure.
- D. Mild fatigue.
Correct Answer: B
Rationale: Decreased pulse rate (bradycardia) may indicate increased intracranial pressure, a sign of worsening neurological status.
Before surgery for a known aortic aneurysm, the client's pulse pressure begins to widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for:
- A. Low blood pressure
- B. Anxiety
- C. Headache
- D. Disorientation
Correct Answer: D
Rationale: Widening pulse pressure and aortic arch involvement in an aortic aneurysm suggest possible dissection affecting cerebral perfusion (e.g., carotid artery involvement), leading to disorientation or neurologic changes. Low blood pressure, anxiety, and headache are less specific or unrelated.
When a client cannot read or write but is of sound mind, the nurse should read the consent to the client in the presence of two witnesses and:
- A. Have the client's next-of-kin sign the consent.
- B. Have the client put an 'X' on the signature line.
- C. Have a court appoint a guardian for the client.
- D. Have a hospital quality management coordinator sign for the client.
Correct Answer: B
Rationale: For a client of sound mind who cannot read/write, reading the consent and having the client mark an 'X' with two witnesses ensures legal informed consent without requiring a guardian.
The nurse is teaching a 17-year-old client and the client's family about what to expect with high-dose chemotherapy. Which of the following side effects should be included in the teaching plan?
- A. Fever.
- B. Chills.
- C. Tachycardia.
- D. Dyspnea.
Correct Answer: A
Rationale: Fever is a common side effect of high-dose chemotherapy due to neutropenia and increased infection risk, and should be included in the teaching plan.
Following a total hip replacement, the nurse should do which of the following? Select all that apply.
- A. With the aid of a coworker, turn the client from the supine to the prone position every 2 hours.
- B. Encourage the client to use the overhead trapeze to assist with position changes.
- C. For meals, elevate the head of the bed to 90 degrees.
- D. Use a fracture bedpan when needed by the client.
- E. When the client is in bed, prevent thromboembolism by applying thigh-high antiembolism stockings.
Correct Answer: B,D,E
Rationale: Using a trapeze, fracture bedpan, and antiembolism stockings supports recovery and prevents complications. Prone positioning and 90-degree elevation risk dislocation.