Nokea
The nurse assesses the client 6 hours following a lumbar spinal fusion. The client has a throbbing headache, but VS and CMS of the lower extremities are WNL. The lungs have fine basilar crackles. The back dressing has a dime-sized bloody spot surrounded by clear yellow drainage. Which nursing action demonstrates the nurse's best clinical judgment?
- A. Give prescribed morphine sulfate IV
- B. Have the client cough and deep breathe
- C. Reinforce the incisional dressing
- D. Notify the health care provider
Correct Answer: D
Rationale: D. A bloody area surrounded by clear yellowish fluid on the dressing and the client's headache suggest a CSF leak. The nurse should notify the HCP.
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The client diagnosed with rule-out osteosarcoma asks the nurse, 'Why am I having a bone scan?' Which statement is the nurse’s best response?
- A. You seem anxious. Tell me about your anxieties.'
- B. Why are you concerned? Your HCP ordered it.'
- C. I’ll have the radiologist come back to explain it again.'
- D. A bone scan looks for cancer or infection inside the bones.'
Correct Answer: D
Rationale: A bone scan detects cancer or infection, directly answering the client’s question. Addressing anxiety, deferring to the HCP, or radiologist involvement is less informative.
Which signs/symptoms indicate to the nurse the client has developed osteoporosis?
- A. The client has lost one (1) inch in height.
- B. The client has lost 12 pounds in the last year.
- C. The client's hands are painful to the touch.
- D. The client's serum uric acid level is elevated.
Correct Answer: A
Rationale: Height loss indicates vertebral compression fractures, a common osteoporosis sign. Weight loss, hand pain, and uric acid elevation are unrelated.
The nurse is caring for a client who has just had a cast applied. Which statement best describes the expected client outcome relative to the circulatory system for a client with a cast?
- A. There will be no increase in pain in the extremity.
- B. The client will have no circulatory impairment.
- C. The integrity of the cast will be maintained.
- D. The client will report any feelings of skin irritation.
Correct Answer: B
Rationale: The primary circulatory outcome is preventing impairment, such as swelling or color changes. Pain relates to neurological issues, cast integrity is unrelated to circulation, and skin irritation is not a circulatory indicator.
The HCP is adducting the newborn's hip while pushing the thigh forward to detect developmental dysplasia of the hip (DDH). The nurse should identify this screening test as which maneuver?
- A. Barlow maneuver
- B. Pavlik maneuver
- C. Gowers maneuver
- D. Allis maneuver
Correct Answer: A
Rationale: The Barlow maneuver involves adducting the hip and pushing the thigh to detect DDH by assessing for hip dislocation.
The nurse is concerned about the spinal curve in the young child and documents the exaggerated lumbar curve. Which condition was likely documented?
- A. Scoliosis
- B. Lordosis
- C. Kyphosis
- D. Kyphoscoliosis
Correct Answer: B
Rationale: Lordosis is characterized by an exaggerated lumbar curve.