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A nurse is caring for a patient who is postoperative following a lumbar laminectomy. Which of the following positions should the nurse encourage? Which position should the nurse encourage post-lumbar laminectomy?
- A. Supine with knees flexed
- B. Prone with a pillow under the abdomen
- C. Side-lying with knees bent
- D. High Fowler's with legs elevated
Correct Answer: C
Rationale: The correct answer is C: Side-lying with knees bent. This position helps to reduce pressure on the surgical site, promotes proper alignment of the spine, and reduces the risk of complications such as nerve compression. Supine with knees flexed (A) may cause excessive pressure on the surgical site. Prone with a pillow under the abdomen (B) can increase strain on the back. High Fowler's with legs elevated (D) may increase pressure on the surgical site and hinder proper spine alignment.
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A nurse assumes various roles while working with patients. Which of the following describes the nursing role of protecting the patient and supporting the patient's decisions? Which role involves protecting and supporting patient decisions?
- A. Advocate
- B. Manager
- C. Caregiver
- D. Educator
Correct Answer: A
Rationale: The correct answer is A: Advocate. Nurses act as advocates by protecting the patient's rights, ensuring their voice is heard, and supporting their decisions. Advocacy involves standing up for the patient's best interests and promoting autonomy. The other choices are incorrect because: B: Manager focuses on organizing and coordinating care, C: Caregiver involves providing direct physical and emotional care, and D: Educator focuses on providing information and teaching. Advocacy uniquely encompasses protecting and supporting the patient's decisions, making it the most appropriate choice in this scenario.
A nurse is attending to a patient with a wound infection. What should the nurse do when collecting a wound-drainage specimen for culture? What should the nurse do for wound culture collection?
- A. Swab an area of skin away from the wound to identify the usual flora.
- B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
- C. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.
- D. Include intact skin at the wound edges in the culture.
Correct Answer: C
Rationale: The correct answer is C: Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. This step is essential to ensure that the sample collected is not contaminated with external bacteria, which could lead to inaccurate results. By cleansing the wound with a sterile solution like saline, the nurse can remove debris and bacteria from the wound surface, increasing the likelihood of obtaining an accurate culture. Swabbing an area away from the wound (choice A) would not provide an accurate representation of the bacteria present in the wound. Irrigating the wound with an antiseptic (choice B) could potentially interfere with the culture results by killing the bacteria being tested for. Including intact skin at the wound edges in the culture (choice D) is unnecessary and could introduce contaminants. Overall, choice C is the most appropriate step to ensure a reliable wound culture.
A nurse is providing health promotion education to the parents of a toddler. Which information should the nurse include in the teaching?,Which information should be included in toddler health promotion education?
- A. Need for increased caloric intake.
- B. How to establish trust.
- C. Management of tantrums.
- D. How to encourage cooperative play.
- E. Dental care.
Correct Answer: A,C,D,E
Rationale: The correct answer includes information on caloric intake (A) to ensure the toddler's proper growth and development. Management of tantrums (C) is crucial for behavioral management. Encouraging cooperative play (D) fosters social skills. Dental care (E) is essential for oral health. Establishing trust (B) is important but not directly related to health promotion. No information is given for choices F and G.
A nurse is educating a patient with benign prostatic hypertrophy who has been newly prescribed finasteride. What should the nurse include in the teaching? What should the nurse include in finasteride teaching?
- A. Decreased libido is an adverse effect of the medication.
- B. Avoid drinking grapefruit juice when taking this medication.
- C. PSA levels will increase while taking this medication.
- D. Expect to see a response from the medication within one week.
Correct Answer: A
Rationale: The correct answer is A: Decreased libido is an adverse effect of the medication. Finasteride is a 5-alpha reductase inhibitor commonly used to treat benign prostatic hypertrophy. One of the common side effects of finasteride is a decrease in libido due to its mechanism of action on hormone levels. This information is crucial for the patient to be aware of to monitor and report any changes in sexual function. Choice B is incorrect because grapefruit juice does not interact with finasteride. Choice C is incorrect as PSA levels typically decrease with finasteride treatment. Choice D is incorrect as it may take several months to see a response from the medication due to its mechanism of action on prostate size.
A nurse is providing dietary education for a patient who has a new prescription for a monoamine oxidase inhibitor (MAOI). Which items in the patient's sample lunch menu would require intervention by the nurse? Which lunch menu item requires intervention for MAOI?
- A. Celery sticks
- B. Sliced apples
- C. Bologna sandwich
- D. Glass of whole milk
Correct Answer: C
Rationale: The correct answer is C: Bologna sandwich. MAOIs interact with tyramine, which can lead to a hypertensive crisis. Bologna is a high-tyramine food that can cause this reaction. Celery, apples, and milk are low in tyramine and safe to consume with MAOIs. Therefore, the bologna sandwich requires intervention to prevent potential adverse effects.