Nokea
The nurse is caring for a patient following a laminectomy with a spinal fusion who reports numbness and tingling of the right lower leg. Which of the following actions should the nurse do first?
- A. Report the patient's symptoms to the surgeon.
- B. Check the vital signs for indications of hemorrhage.
- C. Turn the patient to the side to relieve pressure on the right leg.
- D. Document the findings and reassess the patient in two hours.
Correct Answer: A
Rationale: Numbness and tingling should be immediately reported to the surgeon rather than documented and rechecked in two hours. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient will not relieve the numbness.
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Which of the following statements by a patient with osteosarcoma of the right tibia who is scheduled for an above-the-knee amputation indicates that patient teaching is needed?
- A. I did not have this bone cancer until my leg broke a week ago.
- B. I wish that I did not have to have chemotherapy after this surgery.
- C. I know that I will need to participate in physical therapy after surgery.
- D. I will use the patient-controlled analgesia (PCA)
Correct Answer: A
Rationale: The statement that the patient did not have bone cancer until the leg broke indicates a misunderstanding, as osteosarcoma is a primary bone cancer that may lead to fractures, not vice versa. The other statements reflect appropriate understanding of the need for chemotherapy, physical therapy, and pain management post-surgery.
The nurse is caring for a patient who underwent a laminectomy and discectomy for a herniated intervertebral disc. Following the surgery, which of the following actions should the nurse implement when positioning the patient on their side?
- A. Instruct the patient to move their legs before turning the rest of the body.
- B. Have the patient turn by grasping the side rails and pulling the shoulders over.
- C. Place a pillow between the patient's legs and turn the entire body as a unit.
- D. Turn the patient's head and shoulders first, followed by the hips, legs, and feet.
Correct Answer: C
Rationale: The spine should be kept in correct alignment after laminectomy. The other positions will create misalignment of the spine.
The nurse is caring for a patient who has had a surgical reduction of an open fracture of the left tibia. Which of the following assessment findings is most important to report to the health care provider?
- A. Left leg muscle spasms
- B. Serious wound drainage
- C. Left leg pain with movement
- D. Temperature 38.6°C (101.5°F)
Correct Answer: D
Rationale: An elevated temperature is suggestive of possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture.
The nurse is preparing to administer alendronate to a patient with osteoporosis. Which of the following actions will the nurse implement initially?
- A. Ensure the patient has recently eaten.
- B. Ask about any leg cramps or hot flashes.
- C. Assist the patient to sit up at the bedside.
- D. Administer the prescribed calcium carbonate.
Correct Answer: C
Rationale: To avoid esophageal erosions, the patient taking bisphosphonates should be upright for at least 30 minutes after taking the medication. Fosamax should be taken on an empty stomach, not after taking other medications or eating. Leg cramps and hot flashes are not adverse effects of bisphosphonates.
The nurse is teaching a patient with persistent back pain, whose work involves lifting, about proper body mechanics. Which of the following patient statements indicates that the teaching has been effective?
- A. I plan to start doing exercises to strengthen the muscles of my back.
- B. I will try to sleep with my hips and knees extended to prevent back strain.
- C. I can tell my boss that I need to change to a job where I can work at a desk.
- D. I will keep my back straight when I need to lift anything higher than my waist.
Correct Answer: A
Rationale: Exercises can help to strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back. Modifications in the way the patient lifts boxes is needed as well as reminding that sitting for prolonged periods can aggravate back pain. The patient should not lift above the level of the elbows.