Nokea
The client is 12-hours post-lumbar laminectomy. Which nursing interventions should be implemented?
- A. Assess ability to void and log roll the client every two (2) hours.
- B. Medicate with IV steroids and keep the bed in a Trendelenburg position.
- C. Place sandbags on each side of the head and give cathartic medications.
- D. Administer IV anticoagulants and place on O2 at eight (8) L/min.
Correct Answer: A
Rationale: Post-lumbar laminectomy, assessing voiding prevents urinary retention, and log rolling maintains spinal alignment. Steroids/Trendelenburg, sandbags/cathartics, and anticoagulants/O2 are inappropriate without specific indications.
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The client is postoperative open reduction and internal fixation (ORIF) of a fractured femoral neck. Which long-term goal should the nurse identify for the client?
- A. The client will maintain vital signs within normal limits.
- B. The client will have a decrease in muscle spasms in the affected leg.
- C. The client will have no signs or symptoms of infection.
- D. The client will be able to ambulate down to the nurse’s station.
Correct Answer: D
Rationale: Ambulation to the nurse’s station is a long-term goal post-ORIF, indicating restored mobility. Vital signs, spasms, and infection are short-term or secondary.
The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change-of-shift report?
- A. The 84-year-old female with a fractured right femoral neck in Buck’s traction.
- B. The 64-year-old female with a left total knee replacement who has confusion.
- C. The 88-year-old male post-right total hip replacement with an abduction pillow.
- D. The 50-year-old postop client with a continuous passive motion (CPM) device.
Correct Answer: B
Rationale: Confusion post-TKR may indicate neurological or metabolic complications, requiring urgent assessment. Fractures, THR, and CPM use are stable.
The client who has sustained a left-sided cerebrovascular accident (stroke) has residual right-sided paralysis. The nurse identifies a concept of impaired functional ability. Which should be included in the care map? Select all that apply.
- A. Refer to the occupational therapist.
- B. Assess the client for neglect of the right side.
- C. Place the client in a room where the door is on the left side.
- D. Teach the client to call for assistance prior to getting out of bed.
- E. Encourage the client to participate in physical therapy daily.
Correct Answer: A,B,D,E
Rationale: OT referral, neglect assessment, fall prevention, and PT promote functional ability post-stroke. Room orientation is less critical.
Of the following emergency measures, which one should the nurse perform first?
- A. Check the victim's breathing.
- B. Cover the victim with a blanket.
- C. Move the victim to the curb.
- D. Assess the victim for injuries.
Correct Answer: A
Rationale: In an emergency, the nurse must first assess the victim's breathing to ensure airway patency and adequate oxygenation, following the ABCs (Airway, Breathing, Circulation) of basic life support. Other actions are secondary.
The physician orders that the client with a hip prosthesis may be out of bed to sit in a chair. How should the nurse position the chair to facilitate transferring the client to the side?
- A. At the end of the bed
- B. Perpendicular to the bed
- C. Parallel with the bed
- D. Against a side wall
Correct Answer: C
Rationale: Positioning the chair parallel to the bed allows the client to transfer safely to the nonoperative side, maintaining hip alignment and minimizing the risk of dislocation during the transfer.