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A nurse is planning care for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate independently.
- B. Turn the client by log rolling with a turning sheet.
- C. Position the client in a high Fowlers position.
- D. Apply a heating pad to the lower back.
Correct Answer: B
Rationale: The correct answer is B: Turn the client by log rolling with a turning sheet. This is the correct intervention because after a lumbar laminectomy, it is crucial to protect the surgical site and avoid bending or twisting the spine. Log rolling with a turning sheet helps maintain proper alignment and prevent injury to the surgical area.
Choice A is incorrect because encouraging the client to ambulate independently may put stress on the surgical area. Choice C is incorrect as positioning the client in a high Fowler's position may also strain the spine. Choice D is incorrect because applying a heating pad to the lower back can increase the risk of burns and should be avoided near a surgical site.
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A nurse is providing teaching to a group of clients about the prevention of coronary artery disease. Which of the following information should the nurse include in the teaching?
- A. Walk 30 min daily at a comfortable pace.
- B. Avoid all sources of dietary fat.
- C. Increase sodium intake to prevent dehydration.
- D. Only exercise if experiencing symptoms.
Correct Answer: A
Rationale: Correct Answer: A: Walk 30 min daily at a comfortable pace.
Rationale: Regular physical activity, such as walking, helps prevent coronary artery disease by improving cardiovascular health, maintaining a healthy weight, and reducing stress. Walking for 30 minutes daily at a comfortable pace can improve circulation, lower blood pressure, and reduce the risk of developing heart disease.
Summary of other choices:
B: Avoiding all sources of dietary fat is not recommended as the body needs healthy fats for various functions.
C: Increasing sodium intake does not prevent coronary artery disease and can actually contribute to hypertension, a risk factor for the disease.
D: Only exercising when experiencing symptoms is not proactive in preventing coronary artery disease and may lead to missed opportunities for prevention.
A nurse is teaching a client how to obtain a specimen at home for a fecal occult blood test. Which of the following actions should the nurse instruct the client to take for 3 days prior to collecting the specimen?
- A. Avoid eating red meat.
- B. Increase fiber intake.
- C. Take an iron supplement.
- D. Drink grapefruit juice.
Correct Answer: A
Rationale: The correct answer is A: Avoid eating red meat. Red meat can cause false positives in fecal occult blood tests due to the presence of heme iron which can be mistaken for blood. Instructing the client to avoid red meat for 3 days prior to collecting the specimen helps to ensure the accuracy of the test results.
Summary:
B: Increasing fiber intake does not directly impact the accuracy of the fecal occult blood test.
C: Taking an iron supplement can interfere with the test results by increasing the amount of iron in the stool, leading to false positives.
D: Drinking grapefruit juice is not relevant to the accuracy of the fecal occult blood test.
A home health nurse is inspecting a clients residence for electrical hazards as part of the agencys quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?
- A. An IV pump is plugged into an outlet near a sink.
- B. A lamp with a short cord is used in the bedroom.
- C. A television is plugged into a surge protector.
- D. The client uses a nightlight in the hallway.
Correct Answer: A
Rationale: Correct Answer: A. An IV pump is plugged into an outlet near a sink.
Rationale: Plugging an IV pump near a sink poses a significant risk of electrical shock due to water exposure. Water conducts electricity and can lead to electrocution. This situation directly violates electrical safety guidelines.
Summary of other choices:
B. A lamp with a short cord in the bedroom: While a short cord may not be ideal, it does not pose an immediate safety hazard unless it is frayed or damaged.
C. A television plugged into a surge protector: This is a safe practice as surge protectors help prevent damage from power surges and do not pose a direct safety hazard.
D. The client uses a nightlight in the hallway: Nightlights are commonly used for safety and do not typically pose an electrical hazard if used correctly.
A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider?
- A. Drowsiness
- B. Gingival hyperplasia
- C. Skin rash
- D. Mild nausea
Correct Answer: C
Rationale: The correct answer is C: Skin rash. This is because phenytoin can cause severe and potentially life-threatening skin reactions like Stevens-Johnson syndrome or toxic epidermal necrolysis. These reactions can progress rapidly, so immediate medical attention is crucial. Drowsiness (A) is a common side effect of phenytoin but not typically an emergency. Gingival hyperplasia (B) and mild nausea (D) are common side effects that do not require immediate reporting.
A nurse is providing preoperative teaching about stool consistency to a client who will undergo a colectomy with the placement of an ileostomy. Which of the following information about stool consistency should the nurse include in the teaching?
- A. The stool will be firm and well-formed.
- B. The stool will have a high volume of liquid.
- C. The stool will be similar to normal bowel movements.
- D. The stool will be hard and difficult to pass.
Correct Answer: B
Rationale: The correct answer is B: The stool will have a high volume of liquid. Following a colectomy with an ileostomy, the client will have fecal output from the small intestine, resulting in a high volume of liquid stool. This is because the large intestine, responsible for absorbing water and forming solid stool, is bypassed with an ileostomy. Choice A is incorrect because the stool will not be firm and well-formed. Choice C is incorrect because the stool will not be similar to normal bowel movements due to the absence of the large intestine. Choice D is incorrect as the stool will not be hard and difficult to pass.