Nokea
The nurse is caring for a 13-year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?
- A. Raise the head of the bed at least 30 degrees
- B. Encourage ambulation within 24 hours
- C. Maintain in a flat position, logrolling as needed
- D. Encourage leg contraction and relaxation after 48 hours
Correct Answer: C
Rationale: In the immediate post-operative period following spinal fusion for scoliosis in a 13-year-old, it is important to maintain the patient in a flat position and perform logrolling as needed. This helps prevent injury to the surgical site and ensures proper spinal alignment. Raising the head of the bed at least 30 degrees is contraindicated as it can put strain on the surgical site. Encouraging ambulation within 24 hours may be appropriate in the recovery process but not in the immediate post-operative period. Encouraging leg contraction and relaxation after 48 hours may also be part of the rehabilitation process but is not a priority in the immediate post-operative period.
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A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
- A. Instruct the client to maintain a regular diet the day prior to the examination
- B. Restrict the client's fluid intake 4 hours prior to the examination
- C. Administer a laxative to the client the evening before the examination
- D. Inform the client that only 1 x-ray of his abdomen is necessary
Correct Answer: C
Rationale: Administering a laxative to the client the evening before the examination is the correct action. Bowel prep is crucial for an Intravenous Pyelogram (IVP) as it helps in achieving better visualization of the bladder and ureters. Instructing the client to maintain a regular diet the day prior to the examination (Choice A) is not the appropriate preparation for an IVP. Restricting the client's fluid intake 4 hours prior to the examination (Choice B) is not necessary for this test. Informing the client that only 1 x-ray of his abdomen is necessary (Choice D) is not relevant to the preparation process for an IVP.
Application - The nurse is caring for a patient who has the following labs: Creatinine 2.5mg/dL, WBC 11,000 cells/mL, and Hemoglobin of 12 g/dL. Based on this information, which of these orders would the nurse question?
- A. Administer 30 Units of Lantus Daily
- B. CT of the spine with contrast
- C. X-ray of the abdomen and chest
- D. Administer heparin subcutaneously 5,000 Units every 12 hours
Correct Answer: B
Rationale: The correct answer is to question the order for a CT of the spine with contrast. The patient's elevated creatinine level of 2.5mg/dL indicates impaired kidney function. Contrast agents are nephrotoxic and can further compromise kidney function in patients with existing nephropathy. Therefore, it is crucial to avoid contrast-enhanced imaging studies in patients with impaired renal function.
Choice A: Administering 30 Units of Lantus Daily is not contraindicated based on the provided lab values.
Choice C: Ordering an X-ray of the abdomen and chest is not contraindicated based on the provided lab values.
Choice D: Administering heparin subcutaneously at 5,000 Units every 12 hours is not contraindicated based on the provided lab values.
A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?
- A. Oculogyric crisis
- B. Tardive dyskinesia
- C. Nystagmus
- D. Dysphagia
Correct Answer: A
Rationale: Oculogyric crisis is a known side effect of antipsychotic medications like Haloperidol (Haldol) and is characterized by involuntary upward deviation of the eyes. This condition can be distressing to both the client and their family. Tardive dyskinesia (Choice B) is a different side effect characterized by repetitive, involuntary movements, especially of the face and tongue, which can occur with long-term antipsychotic use. Nystagmus (Choice C) is an involuntary eye movement that is rhythmic and can occur for various reasons but is not specific to Haloperidol use. Dysphagia (Choice D) refers to difficulty swallowing and is not typically associated with the use of Haloperidol.
The nurse is planning care for a client during the acute phase of a sickle cell vasoocclusive crisis. Which of the following actions would be most appropriate?
- A. Fluid restriction to 1000cc per day
- B. Ambulate in the hallway 4 times a day
- C. Administer analgesic therapy as ordered
- D. Encourage increased caloric intake
Correct Answer: C
Rationale: Administering analgesic therapy as ordered is the most appropriate action during the acute phase of a sickle cell vasoocclusive crisis. In this phase, the primary focus is on managing the severe pain experienced by the individual. Analgesic therapy helps alleviate the pain and discomfort associated with the crisis. The other options are not the priority during this phase. Fluid restriction is not recommended as hydration is crucial in managing a vasoocclusive crisis. Ambulation may worsen the pain and should be minimized during this phase. Encouraging increased caloric intake is not directly related to managing the acute phase of a vasoocclusive crisis.
The healthcare provider is educating a parent about side effects of routine immunizations. Which of the following must be reported immediately?
- A. Irritability
- B. Slight edema at the injection site
- C. Local tenderness
- D. Temperature of 102.5?F
Correct Answer: D
Rationale: A temperature of 102.5°F or higher following immunization is considered an adverse reaction and should be reported immediately. This could indicate a more serious systemic response to the vaccine. Irritability, slight edema at the injection site, and local tenderness are common, mild side effects of routine immunizations and do not typically require immediate reporting. Other reactions that should be reported immediately include excessive crying for more than 3 hours, seizure activity, and the presence of tender, swollen, or reddened areas at the injection site.