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A nurse is caring for a client who is postoperative following a lumbar laminectomy. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate with a straight back.
- B. Instruct the client to avoid turning at the waist.
- C. Allow the client to sit in a chair for 2 hr at a time.
- D. Apply a heating pad to the surgical site.
Correct Answer: B
Rationale: Avoiding waist turning prevents strain on the surgical site. Ambulation should allow natural posture, prolonged sitting risks stiffness, and heating pads may increase swelling.
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A nurse is reinforcing teaching with a client who has a new prescription for venlafaxine. Which of the following statements should the nurse include?
- A. You should take this medication with food.
- B. You might experience headaches while taking this medication.
- C. You need to avoid caffeine while taking this medication.
- D. You can expect symptom relief within 24 hours.
Correct Answer: B
Rationale: Venlafaxine can cause headaches, a common side effect. Food enhances absorption, caffeine isn't restricted, and relief takes weeks.
A nurse is caring for a client who is receiving a unit of packed red blood cells. Which of the following actions should the nurse take?
- A. Infuse the blood over 6 hr.
- B. Check the client's temperature every 30 min.
- C. Administer the blood through a 22-gauge IV catheter.
- D. Flush the IV line with dextrose 5% in water before infusion.
Correct Answer: B
Rationale: Monitoring temperature every 30 minutes detects transfusion reactions early. Blood infuses over 2-4 hours, requires a large-gauge catheter, and saline, not dextrose, is used.
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?
- A. Suction the tube every 2 hr.
- B. Secure the tube to the client's face.
- C. Monitor the client's cuff pressure daily.
- D. Reposition the client every 4 hr.
Correct Answer: B
Rationale: Securing the tube prevents dislodgement, ensuring airway safety. Suctioning is as needed, cuff pressure checks are frequent, and repositioning is every 2 hours.
A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. Which of the following statements should the nurse include?
- A. You should take this medication in the morning.
- B. You might experience muscle pain while taking this medication.
- C. You need to avoid eating grapefruit while taking this medication.
- D. You should stop taking this medication if you feel dizzy.
Correct Answer: B
Rationale: Atorvastatin can cause myopathy, so muscle pain should be monitored. It's taken at night, grapefruit interaction is minimal, and dizziness doesn't warrant stopping.
A nurse is reinforcing teaching with a client who has a new prescription for insulin glargine. Which of the following instructions should the nurse include?
- A. Take this insulin with meals.
- B. You might gain weight while taking this insulin.
- C. Shake the vial before drawing up the insulin.
- D. Use this insulin only when your blood sugar is high.
Correct Answer: B
Rationale: Insulin glargine can cause weight gain, a side effect to monitor. It's taken daily, not with meals, shaking is avoided, and it's not for acute highs.