Nokea
The nurse is caring for a client newly admitted to the medical-surgical unit. Which clinical data is most helpful in assessing the client's fall risk?
- A. observing the client's gait and balance
- B. the client's ability to turn from side to side while in bed
- C. interviewing close family members about the client's gait and balance
- D. the client's self-report on their gait and balance
Correct Answer: A
Rationale: Direct observation of gait and balance provides the most reliable data for assessing fall risk.
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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.
The nurse is caring for a client with an indwelling urinary catheter connected to a drainage bag. The nurse demonstrates effective care when. Select all that apply.
- A. Emptying the drainage bag when it is half full.
- B. Collecting a urine specimen for culture from the port in drainage tubing.
- C. Clamping the urinary catheter tubing prior to discontinuation.
- D. Instructing the client to carry the collection bag above their bladder during ambulation.
- E. The tubing goes in and out of the urethra during cleaning.
Correct Answer: A,B
Rationale: Emptying when half full prevents reflux, and collecting from the port ensures sterility. Clamping is unnecessary, carrying above the bladder risks reflux, and tubing movement risks infection.
Item 1 of 1 • Assessment
Neurological: Alert and Oriented x 4; anxious affect
Cardiovascular: S1, S2 heart tones; all peripheral pulses palpable; no edema
Gastrointestinal: Distended abdomen; absent bowel sounds; hiccups; reports persistent nausea
Genitourinary: Denies dysuria; voiding every 3-4 hours with straw-colored urine
Musculoskeletal: Full range of motion in all extremities; steady gait
Integumentary: Incision is approximated; moderate dry sanguineous drainage was noted on the dressing.
Pain: Reports incision pain as a 3 based on a scale of 0-10.
• Vital Signs
Blood Pressure 119/75 mm Hg
Temperature 99° F (37° C)
Heart rate 90/min
Respiratory rate 17 breaths per minute
Oxygen saturation 97% on room air
The nurse is caring for a client two days postoperative following a partial colectomy.Complete the sentence below from the list of options: The client is at risk of developing
--------------based on the client’s------------------------
- A. paralytic ileus
- B. wound infection
- C. intractable pain
- D. integumentary assessment
- E. pain assessment
- F. gastrointestinal assessment
Correct Answer: A,F
Rationale: The client exhibits signs of paralytic ileus, as evidenced by the gastrointestinal assessment findings (distended abdomen, absent bowel sounds, nausea, and hiccups).
The clinical data do not support wound infection as it is too early in the postoperative period for this to occur, and the client has no other manifestations supporting this finding.
Pain is expected in the postoperative period, and the current pain rating is mild-to-moderate (3). In contrast, intractable pain would be suggested by pain not relieved by medication and at a severe level.
The nurse and two unlicensed assistive personnel (UAP) are preparing to reposition a client who requires log rolling. Which actions would be appropriate? Select all that apply.
- A. Place a small pillow between the client's knees.
- B. Places the client's arms at their side.
- C. Fanfold a drawsheet along the backside of the client.
- D. Instruct the client to laterally flex the neck during the turn.
- E. Roll the client as one unit in a smooth, continuous motion.
Correct Answer: A,B,C,E
Rationale: Pillow placement, arms at sides, drawsheet use, and rolling as a unit maintain spinal alignment. Neck flexion risks injury during log rolling.
The nurse is teaching a client how to ambulate using crutches. Which of the following information should the nurse include?
- A. Keep the crutches 4 in (10 cm) in front of your feet while standing.
- B. When ascending stairs, lead with your unaffected (stronger) leg.
- C. Before sitting down in a chair, move both crutches to the unaffected (stronger) side of the body.
- D. Your shoulders should support your body weight while ambulating with crutches.
Correct Answer: B
Rationale: Leading with the stronger leg when ascending stairs ensures stability. Crutches should be 6-10 inches forward, crutches stay in both hands when sitting, and weight is on hands, not shoulders.