Nokea
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.
You may also like to solve these questions
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 paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.)
- A. Perform range-of-motion (ROM) exercises for the hip joint.
- B. Reposition the client off of the reddened areas.
- C. Get the client out of bed and into a chair once a day.
- D. Obtain a low-air-loss mattress to minimize pressure.
- E. Apply a barrier cream to the reddened areas.
Correct Answer: B,D
Rationale: Repositioning and using a low-air-loss mattress relieve pressure on reddened areas. Rubbing, barrier creams, ROM exercises, and sitting in a chair do not address pressure relief effectively.
A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this client's discharge teaching?
- A. Take warm baths to promote muscle relaxation.
- B. Avoid people with upper respiratory illnesses.
- C. Relying on a walker will weaken your gait.
- D. Take prescribed medication only when symptoms occur.
Correct Answer: B
Rationale: Clients taking cyclophosphamide and methylprednisolone are immunocompromised and should avoid people with upper respiratory illnesses to prevent infections. Warm baths may help but are not the priority, relying on a walker does not necessarily weaken gait, and medications should be taken as prescribed, not only when symptoms occur.
A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first?
- A. Pain at the surgical site.
- B. Numbness in the lower extremities.
- C. Difficulty breathing.
- D. Weak pedal pulses.
Correct Answer: C
Rationale: Difficulty breathing could indicate a compromised airway, possibly due to swelling, which is a critical postoperative complication requiring immediate attention. Pain, numbness, and weak pulses are important but not as urgent as airway issues.
A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.)
- A. Heart rate of 34 beats/min
- B. Blood pressure of 90/60 mm Hg
- C. Cool and clammy skin
- D. Decreased urinary output
- E. Flaccid paralysis below the injury
Correct Answer: A,B,C,D,E
Rationale: Neurogenic shock from a T5 spinal cord injury can cause bradycardia (low heart rate), hypotension (low blood pressure), cool and clammy skin, decreased urinary output due to reduced perfusion, and flaccid paralysis below the injury level.