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A nurse is caring for a client who is postoperative following a lumbar puncture. Which of the following actions should the nurse take?
- A. Encourage the client to lie flat for 2 to 4 hr.
- B. Instruct the client to limit fluid intake.
- C. Apply a warm compress to the puncture site.
- D. Monitor the client's temperature every 8 hr.
Correct Answer: A
Rationale: Lying flat prevents post-lumbar puncture headache by reducing CSF leakage. Fluid restriction is unnecessary, warm compresses aren't standard, and temperature checks are more frequent if infection is suspected.
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A nurse is reinforcing discharge teaching with the caregiver of a client who has a dependent personality disorder. Which of the following instructions should the nurse include in the teaching?
- A. Limit the client's social interactions.
- B. Encourage the client to be assertive.
- C. Assume responsibility for making the client's decisions.
- D. Maintain a verbal no-harm contract with the client.
Correct Answer: B
Rationale: Encouraging assertiveness promotes independence, countering dependency tendencies. Limiting interactions or making decisions for the client reinforces dependence, and no-harm contracts are unrelated.
A nurse is caring for a client who is receiving chemotherapy. Which of the following actions should the nurse take?
- A. Encourage the client to eat raw fruits and vegetables.
- B. Monitor the client's white blood cell count.
- C. Administer an antipyretic every 4 hr.
- D. Instruct the client to avoid handwashing.
Correct Answer: B
Rationale: Monitoring WBC count detects neutropenia, critical for infection prevention. Raw produce risks infection, antipyretics aren't routine, and handwashing is essential.
A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN. Which of the following actions should the nurse take?
- A. Verify the amount of TPN solution the client is receiving every 4 hr.
- B. Prepare the client for a chest x-ray to verify catheter placement.
- C. Place the client in Sims' position for catheter insertion.
- D. Use a clean technique when changing the catheter dressing.
Correct Answer: B
Rationale: A chest X-ray confirms proper central venous catheter placement, critical for safe TPN administration. Verifying solution, Sims' position, or clean technique are inappropriate.
A nurse is reinforcing teaching with a client who has a new prescription for tramadol. Which of the following instructions should the nurse include?
- A. Take this medication with food to prevent nausea.
- B. You might experience constipation while taking this medication.
- C. You should avoid driving until you know how this medication affects you.
- D. You can increase the dose if your pain persists.
Correct Answer: B,C
Rationale: Tramadol can cause constipation, and its sedative effects warrant avoiding driving initially. Food may help nausea but isn't required, and dose increases need provider approval.
A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?
- A. Place the client in a supine position.
- B. Ensure the device is kept below the level of the client's chest.
- C. Empty the collection chamber every 8 hr.
- D. Clamp the chest tube every 4 hr.
Correct Answer: B
Rationale: Keeping the drainage system below chest level ensures proper drainage and prevents backflow. Supine positioning may hinder drainage, routine emptying isn't needed, and clamping can interfere with suction.