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A nurse is caring for a client who is postoperative following a spinal fusion. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate with a back brace.
- B. Instruct the client to twist at the waist when turning.
- C. Apply a heating pad to the surgical site.
- D. Allow the client to sit for 2 hr at a time.
Correct Answer: A
Rationale: A back brace supports ambulation, promoting stability. Twisting risks injury, heating pads may increase swelling, and prolonged sitting strains the spine.
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A nurse is assisting with the care of a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take to prevent aspiration?
- A. Flush the tube with 30 mL of sterile water every 4 hr.
- B. Place the client in a supine position during feeding.
- C. Check for gastric residual volume every 4 hr.
- D. Keep the head of the bed elevated to at least 30 degrees.
Correct Answer: D
Rationale: Elevating the bed to 30-45 degrees reduces aspiration risk by promoting proper digestion. Flushing maintains patency, supine position increases risk, and residual checks monitor tolerance.
A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?
- A. You should lay down for 1 hour following a meal.
- B. You should eat three large meals and two snacks per day.
- C. You should only drink 2 cups of coffee per day.
- D. You should elevate the head of the bed while sleeping.
Correct Answer: D
Rationale: Elevating the bed head prevents acid reflux at night. Lying down post-meal, large meals, or coffee can worsen GERD symptoms.
A nurse is caring for a client who is postoperative following a cesarean birth. Which of the following findings should the nurse report to the provider?
- A. The client reports pain at the incision site.
- B. The client's temperature is 38.5°C (101.3°F).
- C. The client has not voided in 6 hr.
- D. The client's lochia is moderate.
Correct Answer: B
Rationale: A temperature of 38.5°C suggests infection, requiring reporting. Pain, delayed voiding, and moderate lochia are expected or less urgent.
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.
A nurse is reinforcing teaching with a client who has a new prescription for losartan. Which of the following instructions should the nurse include?
- A. Take this medication with a high-potassium meal.
- B. You might feel dizzy when standing up quickly.
- C. You need to limit your exercise.
- D. You should take this medication at bedtime.
Correct Answer: B
Rationale: Losartan can cause orthostatic hypotension, leading to dizziness. Potassium meals, exercise limits, and bedtime dosing aren't necessary.