Nokea
The nurse cares for a client scheduled for spinal surgery in one hour. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe
- A. gentamicin
- B. enoxaparin
- C. hydromorphone
- D. cyclobenzaprine
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, is commonly prescribed preoperatively for spinal surgery to prevent venous thromboembolism due to prolonged immobility. Gentamicin is an antibiotic, hydromorphone is for pain, and cyclobenzaprine is a muscle relaxant, none of which are typically prioritized preoperatively for this purpose.
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The nurse is caring for a postoperative client who is ordered to use an incentive spirometer. The nurse understands that this device will help prevent which complication?
- A. venous thromboembolism
- B. obstructive sleep apnea
- C. hypostatic pneumonia
- D. aspiration pneumonia
Correct Answer: C
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis, reducing the risk of hypostatic pneumonia in postoperative clients with limited mobility. It does not directly prevent venous thromboembolism, obstructive sleep apnea, or aspiration pneumonia.
The nurse is caring for a client admitted with severe pre-eclampsia. It would be essential for the nurse to have which of the following items at the bedside?
- A. One liter of 0.9% saline
- B. Sterile gloves
- C. Portable ultrasound
- D. Suction equipment
Correct Answer: D
Rationale: Severe pre-eclampsia increases seizure risk (eclampsia), requiring suction equipment at the bedside to manage airway secretions during a seizure. Saline, gloves, and ultrasound are not immediate priorities for seizure management.
The nurse is teaching a group of clients strategies to promote effective sleep. The nurse should recommend that the clients Select all that apply.
- A. Empty their bladder before bed.
- B. Take more naps throughout the day.
- C. Eat a high amount of calories before bed.
- D. Plan vigorous exercise earlier in the day.
- E. Use multiple nightlights in the bedroom.
Correct Answer: A,D
Rationale: Emptying the bladder and exercising early promote sleep. Naps, high-calorie meals, and multiple lights disrupt sleep hygiene.
The nurse is observing infection control practices in the nursing unit. Which of the following findings requires follow-up? Select all that apply.
- A. Doors kept closed for clients with contact precautions
- B. Gloves being worn by staff to pass meal trays
- C. Disposable dishes being used for clients on isolation precautions
- D. Bedside fan being removed from a room with negative pressure
- E. Alcohol-based hand sanitizers for a client with C. diff
Correct Answer: B,E
Rationale: Gloves are not required for passing meal trays unless direct contact with infectious material is anticipated. Alcohol-based sanitizers are ineffective against C. difficile; soap and water are required.
The nurse is planning care for a client diagnosed with Mycoplasma pneumonia. The nurse should plan to
- A. place the client in a private room with negative airflow.
- B. wear a surgical mask within 3 feet of the client.
- C. wear gloves when in contact with the client.
- D. provide disposable meal trays and utensils.
Correct Answer: B
Rationale: Mycoplasma pneumonia requires droplet precautions, including a surgical mask within 3 feet. Negative airflow, gloves, and disposable trays are not required.