Nokea
A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)
- A. Surgical discomfort.
- B. Redness and itching at the incision site.
- C. Incisional bulging.
- D. Clear drainage on the dressing.
- E. Sudden and severe headache.
Correct Answer: C,D,E
Rationale: Incisional bulging, clear drainage (possible CSF leak), and severe headache are emergencies post-laminectomy. Surgical discomfort and redness/itching are normal and not urgent.
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A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching?
- A. Stroke the inner aspect of your thigh to initiate voiding.
- B. Implement digital anal stimulation when your bladder is full.
- C. Tighten your abdominal muscles to stimulate urine flow.
- D. Use a catheter to empty your bladder completely.
Correct Answer: C
Rationale: In clients with lower motor neuron injuries, performing a Valsalva maneuver by tightening abdominal muscles can stimulate urine flow. The other options are not effective for achieving bladder control in this context.
A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should the nurse address first?
- A. Associated stridor.
- B. Weak pedal pulses.
- C. Difficulty breathing.
- D. Inability to shrug shoulders.
Correct Answer: C
Rationale: Difficulty breathing indicates a potential airway obstruction, possibly due to postoperative swelling, which is a priority. Stridor and difficulty swallowing are also concerns but maintaining an airway takes precedence. Weak pedal pulses and inability to shrug shoulders are less urgent.
A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?
- A. Administer oxygen via a nasal cannula.
- B. Place the client in a supine position.
- C. Palpate the bladder for distention.
- D. Administer a prescribed beta blocker.
Correct Answer: C
Rationale: The client is manifesting symptoms of autonomic dysreflexia, likely due to bladder distention. Palpating the bladder to check for distention is the first step to identify and address the cause. The other actions are not appropriate as initial responses.
A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions?
- A. Only lift items that are 10 pounds or less.
- B. You must wear a brace throughout the healing process.
- C. You must remain in bed for 3 weeks after surgery.
- D. You are prescribed medications to prevent rejection.
Correct Answer: B
Rationale: Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process to stabilize the spine. The other options are incorrect: lifting restrictions may vary, bed rest for 3 weeks is not typically required, and rejection medications are not needed for spinal fusion.
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?
- A. Peripheral edema
- B. Black and tarry stools
- C. Bradycardia
- D. Nausea and vomiting
Correct Answer: C
Rationale: Fingolimod (Gilenya) can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not typical adverse effects of this medication.