Nokea
The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside?
- A. Overhead trapeze
- B. Abduction pillow
- C. Transfer board
- D. Continuous passive motion (CPM)
Correct Answer: A
Rationale: An overhead trapeze assists with safe repositioning and mobility post-lumbar spinal fusion, reducing strain on the surgical site. Abduction pillows are used for hip surgeries, transfer boards aid general transfers, and CPM is for joint surgeries, not spinal fusion.
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The nurse conducts safety rounds within the nursing unit. Which observation requires followup? Select all that apply.
- A. The client's armband was affixed to the bedside table.
- B. The client's telephone number and name were used as identifiers.
- C. Multiple blood specimen tubes are labeled before specimen collection.
- D. A room number is used as an identifier during medication administration.
- E. Verifies client's name, date of birth, consent, site, and procedure during a time out process.
Correct Answer: A,B,C,D
Rationale: Armbands on tables, using telephone numbers, pre-labeling tubes, and room numbers as identifiers risk errors. Verifying name, date of birth, and procedure details is correct.
The nurse is caring for a client who has a prescribed regular insulin sliding scale. At 0800, the client's capillary blood glucose (CBG) was 258 mg/dl (14.29 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. At 1215 the CBG was 288 mg/dl (15.984 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. At 1730 the CBG was 254 mg/dI (14.097 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. The nurse should do which of the following at 1730?
- A. Administer 8 units of regular insulin
- B. Administer 6 units of regular insulin
- C. Notify the primary health care provider (PHCP)
- D. Withhold the prescribed insulin
- E. Modify the client's prescribed diet to low sodium
Correct Answer: B,C
Rationale: Per the sliding scale, 254 mg/dL requires 6 units of insulin, and three consecutive CBGs >250 mg/dL require notifying the PHCP.
The nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home?
- A. Positive gag reflex
- B. Hypoactive bowel sounds
- C. Blood pressure 90/60 mm Hg
- D. Incisional pain '2' on a scale of 0 to 10
- E. Urinary output of 240 mL since surgery
Correct Answer: A,D,E
Rationale: A positive gag reflex indicates airway protection, mild incisional pain (2/10) suggests adequate pain control, and sufficient urinary output (240 mL) indicates renal function, all supporting discharge readiness. Low blood pressure (90/60 mm Hg) suggests instability, and hypoactive bowel sounds are expected but not a discharge criterion.
The nurse is observing a student perform a physical assessment. It will demonstrate appropriate technique if the student assesses for stereognosis by instructing the client to
- A. Close their eyes, place an object in their hand, and ask them to identify it.
- B. Close their eyes with feet together, arms at the sides, and observe for loss of balance.
- C. Walk on their heels and then on their tiptoes for at least ten feet.
- D. Touch the tip of their nose with the index finger and return the arm to an extended position.
Correct Answer: A
Rationale: Stereognosis is tested by placing an object in the client’s hand with eyes closed to assess tactile recognition. Other options test balance, gait, or coordination.
The nurse is caring for a client who is two days postoperative following a right femoral popliteal bypass surgery. The client reports worsening pain, and the assessment showed swelling and ecchymosis at the incision sites. The nurse should initially
- A. Apply pressure to sites with sandbag
- B. Palpate pedal pulses
- C. Assess for signs of claudication
- D. Apply warm compress to incision sites
Correct Answer: B
Rationale: Worsening pain, swelling, and ecchymosis at the incision sites suggest possible complications such as hematoma or compromised vascular flow. Palpating pedal pulses is the priority to assess the patency of the bypass graft and ensure adequate distal perfusion. Applying pressure or warm compresses could exacerbate bleeding or swelling, and claudication assessment is less urgent than confirming vascular integrity.