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The nurse is caring for a client who is postoperative day 1 after a lumbar laminectomy. Which of the following actions is the PRIORITY?
- A. Encourage the client to log-roll when turning.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Encouraging log-rolling is the priority to prevent spinal strain and maintain alignment post-lumbar laminectomy. Options B, C, and D are important but secondary: pain management, drain monitoring, and incision checks follow proper positioning.
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The nurse is inserting an indwelling urinary catheter in an adult woman. The nurse locates landmarks before inserting the catheter. The urethral opening is located:
- A. above the clitoris.
- B. behind the vagina.
- C. between the clitoris and the vagina.
- D. between the vagina and the rectum.
Correct Answer: C
Rationale: The female urethral opening is located between the clitoris and vagina, a key landmark for catheter insertion to avoid incorrect placement.
A fluid challenge of 250 cc of normal saline infused over 15 min is ordered for a client with possible acute renal failure. The nurse understands that the fluid challenge is given to
- A. rule out dehydration as the cause of oliguria.
- B. increase cardiac output and fluid volume.
- C. promote the transfer of intravascular fluid to the intracellular space.
- D. dilute the level of waste products in the intravascular fluid.
Correct Answer: A
Rationale: expected response after a fluid challenge on normally functioning kidneys is an increase in urine output; will occur if low urine output is due to dehydration; if it is due to acute renal failure, there will continue to be oliguria
The nurse is to insert an indwelling catheter in a male. Which action is appropriate?
- A. Cleanse the meatus before preparing the catheter for insertion
- B. Wash hands before starting the procedure
- C. Hold the penis at a 45-degree angle during insertion of the catheter
- D. Inflate the balloon immediately before inserting the catheter
Correct Answer: B
Rationale: Washing hands before catheter insertion is critical to maintain a sterile field and prevent infection. Cleansing the meatus occurs after hand washing, a 45-degree angle is incorrect (90 degrees is typical), and the balloon is inflated post-insertion.
Which of the following observations best indicates to the nurse that a paraplegic client can adequately carry out activities of daily living at home after discharge?
- A. The client can shave himself and brush his teeth.
- B. The client can transfer himself into and out of his wheelchair.
- C. The client can maneuver his wheelchair without difficulty.
- D. The client can prepare his own well-balanced meals.
Correct Answer: B
Rationale: Transferring into and out of a wheelchair is essential for a paraplegic to perform ADLs independently, enabling mobility and access to other tasks. Shaving, maneuvering the wheelchair, and cooking are important but less critical if transfer ability is impaired.
A client with symptoms supportive of a diagnosis of Guillain-Barré syndrome.
The nurse knows that which of the following symptoms would be supportive of a diagnosis of Guillain-Barré syndrome?
- A. Hemiplegia, hypertension, tachycardia.
- B. Respiratory failure, flaccid paralysis, urinary retention.
- C. Peripheral edema, hypertension, pulmonary congestion.
- D. Diminished reflexes, pain, paresthesia.
Correct Answer: B
Rationale: Strategy: All parts of the answer choice must be correct in order for the answer to be correct. (1) relates to a CVA (2) correct-classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation (3) relates to pulmonary edema (4) relates to peripheral nerve problems