Nokea
The nurse is assessing a client post-laminectomy for complications. Which finding requires immediate action?
- A. Mild incisional pain.
- B. Clear drainage from the incision.
- C. Slight numbness in the toes.
- D. Stable vital signs.
Correct Answer: B
Rationale: Clear drainage may indicate a cerebrospinal fluid leak, a critical complication requiring urgent intervention.
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The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give 'hand-off reports' at which of the following times? Select all that apply.
- A. Change of shift.
- B. Change of nurses.
- C. When nurse goes to lunch.
- D. When unit clerk goes to a staff meeting.
- E. When new medication orders are written.
Correct Answer: A,B,C
Rationale: Hand-off reports are critical at change of shift, change of nurses, and when the nurse goes to lunch to ensure continuity of care and client safety.
A client with a lumbar spinal fusion is preparing for discharge. Which activity should the nurse advise the client to avoid?
- A. Walking short distances daily.
- B. Lifting objects heavier than 10 pounds.
- C. Sleeping on a firm mattress.
- D. Using a recliner for sitting.
Correct Answer: B
Rationale: Lifting heavy objects can strain the surgical site, delaying healing post-spinal fusion.
The nurse is caring for a client receiving mechanical ventilation receiving fentanyl and midazolam. Which of the following assessment findings would indicate fentanyl toxicity?
- A. constricted pupils
- B. hypertension
- C. coarse Tremors
- D. diarrhea
Correct Answer: A
Rationale: Constricted pupils (miosis) are a hallmark of opioid toxicity, including fentanyl, due to its effects on the central nervous system.
The client complains of aching, weakness, and a cramping sensation in both of his lower extremities while walking. The nurse knows that exercise enhances blood circulation and utilization of oxygen by the tissues. To promote health and maintain the client's level of activity, the nurse should suggest that the client try:
- A. Cross-country skiing
- B. Jogging
- C. Golfing
- D. Riding a stationary bike
Correct Answer: D
Rationale: Riding a stationary bike is a low-impact exercise that promotes circulation and oxygen utilization without excessive strain, suitable for PVD clients with claudication. Skiing and jogging may exacerbate symptoms due to high intensity, and golfing involves prolonged standing, which is less beneficial.
The nurse is caring for a client prescribed amphotericin b for a systemic fungal infection. The nurse should anticipate a prescription for which medication before the infusion? Select all that apply
- A. Diphenhydramine
- B. Acetaminophen
- C. 0.9% saline bolus
- D. Regular insulin
- E. Sodium bicarbonate
Correct Answer: A,B,C
Rationale: Amphotericin B infusions can cause infusion reactions and nephrotoxicity. Choice A (diphenhydramine) and Choice B (acetaminophen) are given to prevent infusion reactions like fever and chills. Choice C (0.9% saline bolus) helps protect the kidneys by ensuring adequate hydration. Choice D (insulin) and Choice E (sodium bicarbonate) are not routinely used.