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A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?
- A. Place the client's arms above her head prior to logrolling.
- B. Place the client in semi-Fowler's position prior to logrolling.
- C. Place the bed in the lowest position before logrolling the client.
- D. Place a pillow between the client's legs prior to logrolling.
Correct Answer: D
Rationale: A pillow maintains spinal alignment during logrolling post-laminectomy.
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A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take?
- A. Keep the client's room well lit.
- B. Encourage the client to abstain from distracting activities.
- C. Ensure that the client's room is kept at a cool temperature.
- D. Play music in the client's room.
Correct Answer: D
Rationale: Music distracts from pain and promotes relaxation, a nonpharmacological approach.
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
- A. Use a narrower cuff to repeat the BP measurement.
- B. Request a prescription for an antihypertensive medication.
- C. Measure the client's BP in the other arm.
- D. Deflate the cuff faster when repeating the BP measurement.
Correct Answer: C
Rationale: Measuring in the other arm confirms accuracy of the elevated reading.
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Using a quick-release tie to secure the restraint.
- B. Tying the restraint to the bed frame.
- C. Placing the restraint across the client's chest.
- D. Applying the restraint over the client's gown.
Correct Answer: C
Rationale: Placing the restraint across the chest restricts breathing and is unsafe, requiring intervention.
A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?
- A. Unequal height of the shoulders.
- B. Increased concave curve of the thoracic spine.
- C. Expansion of the upper intercostal spaces.
- D. Increased convex curve of the cervical spine.
Correct Answer: A
Rationale: Unequal shoulder height is a classic sign of scoliosis due to lateral spinal curvature.
A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?
- A. Use a catheter securing device to hold the catheter in place.
- B. Obtain urine from the drainage bag if a urinary specimen is required.
- C. Change the catheter bag every 3 days and as needed.
- D. Position the drainage bag higher than the client's bladder.
Correct Answer: A
Rationale: Securing the catheter prevents movement and reduces infection risk.