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A nurse is planning care for a client who is postoperative following a laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Elevate the client's legs while in bed.
- B. Reposition the client every 2 hours.
- C. Maintain bed rest for the first 24 hours postoperatively.
- D. Ambulate the client on the first postoperative day.
Correct Answer: D
Rationale: Ambulating the client on the first postoperative day is crucial to prevent complications like deep vein thrombosis and aid in the recovery process. Elevating the legs while in bed can help with circulation but is not as effective in preventing complications related to immobility post-surgery. Repositioning every 2 hours is important for preventing pressure ulcers but does not directly address postoperative care. Maintaining bed rest for the first 24 hours postoperatively can increase the risk of complications associated with immobility, making early ambulation a more appropriate intervention.
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A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Encourage the client to take deep breaths.
- B. Place the client in a high-Fowler's position.
- C. Administer a bronchodilator.
- D. Administer oxygen at 6 L/min via face mask.
Correct Answer: B
Rationale: The correct answer is to place the client in a high-Fowler's position. This position helps improve breathing by expanding the lungs and aiding in better oxygenation. Encouraging the client to take deep breaths may not be effective in managing dyspnea in COPD as it can lead to fatigue. Administering a bronchodilator may be necessary but placing the client in a high-Fowler's position should be the priority. Administering oxygen at 6 L/min via face mask may also be needed, but positioning is the initial intervention to optimize respiratory function.
How should a healthcare professional monitor a patient for infection post-surgery?
- A. Monitor the surgical site
- B. Monitor for fever
- C. Check blood pressure
- D. Check for redness
Correct Answer: A
Rationale: Monitoring the surgical site is crucial to identify early signs of infection post-surgery. Redness, swelling, warmth, or discharge at the surgical site can indicate an infection. While monitoring for fever (choice B) is important as fever can also be a sign of infection, it may not always present immediately post-surgery. Checking blood pressure (choice C) is essential for other purposes but not specifically for monitoring infection post-surgery. Checking for redness (choice D) is limited as redness alone may not always indicate an infection, so it is not as comprehensive as monitoring the surgical site.
How should a healthcare professional care for a patient with a stage 2 pressure ulcer?
- A. Clean the area with normal saline
- B. Apply antibiotic ointment
- C. Use a hydrocolloid dressing
- D. Change the dressing daily
Correct Answer: C
Rationale: Using a hydrocolloid dressing is the appropriate care for a stage 2 pressure ulcer because it provides a moist healing environment, promotes healing, and helps to prevent infection. Cleaning the area with normal saline (Choice A) is important but not the primary treatment for a stage 2 pressure ulcer. Applying antibiotic ointment (Choice B) may not be necessary unless there is a sign of infection. Changing the dressing daily (Choice D) may disrupt the healing process and is not recommended unless the dressing is soiled or compromised.
A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include?
- A. Massage the affected extremity every 4 hours.
- B. Encourage the client to remain on bed rest.
- C. Apply cold packs to the affected extremity.
- D. Encourage the client to ambulate frequently.
Correct Answer: C
Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply cold packs to the affected extremity. Cold packs help reduce swelling and pain by causing vasoconstriction. Massaging the affected extremity could dislodge a clot, leading to serious complications. Encouraging bed rest may increase the risk of clot propagation, while frequent ambulation is contraindicated as it can dislodge clots.
A healthcare provider is reviewing laboratory results for a client who is receiving heparin therapy. Which of the following results indicates that the medication is effective?
- A. Platelets 250,000/mm³
- B. aPTT 60 seconds
- C. Hemoglobin 15 g/dL
- D. INR 1.5
Correct Answer: B
Rationale: An aPTT of 60 seconds indicates that the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot and is used to monitor heparin therapy. A therapeutic range for aPTT during heparin therapy is usually 1.5 to 2 times the control value, which is around 25-35 seconds. Platelets, hemoglobin, and INR values are not direct indicators of the effectiveness of heparin therapy.