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The nurse develops a teaching plan for a client scheduled for a spinal fusion. Which of the following should the nurse expect to include?
- A. The client typically experiences more pain at the donor site than at the fusion site.
- B. The surgeon will apply a simple gauze dressing to the donor site.
- C. Neurovascular checks are unnecessary if the fibula is the donor site.
- D. The client's level of activity restriction is determined by the amount of pain.
Correct Answer: A
Rationale: The donor site (e.g., iliac crest) often causes more pain than the fusion site due to tissue trauma.
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When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse expect to assess? Select all that apply.
- A. Epigastric pain at night.
- B. Relief of epigastric pain after eating.
- C. Vomiting.
- D. Weight loss.
- E. Melena.
Correct Answer: A,C,E
Rationale: Gastric ulcers commonly cause epigastric pain at night, vomiting, and melena (dark, tarry stools) due to bleeding. Relief of pain after eating is more typical of duodenal ulcers, and weight loss is less common with gastric ulcers.
The nurse has received a prescription for tenofovir and emtricitabine. The nurse understands that this medication is used to treat
- A. multiple sclerosis.
- B. human immunodeficiency virus (HIV).
- C. Parkinson's disease.
- D. Guillain-Barré syndrome.
Correct Answer: B
Rationale: Tenofovir and emtricitabine (Truvada) are antiretroviral medications used to treat and prevent HIV. They are not used for multiple sclerosis (A), Parkinson’s disease (C), or Guillain-Barré syndrome (D).
In order to prevent recurrent vasospastic episodes with Raynaud's phenomenon, the nurse should instruct the client to:
- A. Keep the hands and feet elevated as much as possible
- B. Use a vibrating massage device on the hands
- C. Wear gloves when obtaining food from the refrigerator
- D. Increase coffee intake to 2 cups per day
Correct Answer: C
Rationale: Wearing gloves when obtaining food from the refrigerator prevents cold-triggered vasospasm in Raynaud's. Elevation is irrelevant, vibrating devices may worsen symptoms, and coffee (caffeine) can cause vasoconstriction, increasing episodes.
Which of the following interventions should the nurse anticipate incorporating into the client's plan of care when hepatic encephalopathy initially develops?
- A. Inserting a nasogastric (NG) tube.
- B. Restricting fluids to 1,000 mL/day.
- C. Administering I.V. salt-poor albumin.
- D. Implementing a low-protein diet.
Correct Answer: D
Rationale: A low-protein diet (D) reduces ammonia production in hepatic encephalopathy. NG tubes (A), fluid restriction (B), and albumin (C) are not primary interventions.
Which pediatric surgery client should not play with a balloon?
- A. A child having her 15th laser surgery for a hemangioma.
- B. A child having a tonsillectomy.
- C. A child having an inguinal hernia repair.
- D. A child having an orchiopexy.
Correct Answer: B
Rationale: A child post-tonsillectomy should avoid balloons, as blowing or playing with them can increase intraoral pressure, risking bleeding or disruption of the surgical site.