Nokea
Which activity is best to begin implementing immediately after the client's surgery?
- A. Standing at the side of the bed
- B. Balancing between parallel bars
- C. Lifting oneself with the trapeze
- D. Transferring from the bed to a chair
Correct Answer: C
Rationale: Lifting with a trapeze strengthens upper body muscles safely immediately post-surgery, preparing for crutch use without stressing the stump. Other activities are more advanced.
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When planning the client's postoperative care, which is the least desirable position in which the nurse can place the client?
- A. Lying supine
- B. Sitting in a chair
- C. Lying prone
- D. Standing to shower
Correct Answer: C
Rationale: Prone positioning stresses the stump and impairs healing.
The nurse knows that a client who sustains multiple fractures of long bones is at risk for developing fat embolism syndrome. Which findings suggest that the client is developing this complication? Select all that apply.
- A. Bradycardia
- B. Petechiae
- C. Dyspnea
- D. Mental status changes
- E. Hypertension
- F. Hematuria
Correct Answer: B,C,D
Rationale: Fat embolism syndrome typically presents with petechiae (small red spots from fat emboli in the skin), dyspnea (from pulmonary involvement), and mental status changes (from cerebral hypoxia). Bradycardia, hypertension, and hematuria are not characteristic.
Before turning the client postoperatively, which nursing instruction is especially important to prevent postoperative complications?
- A. Hold your breath as you are turning.
- B. Move your lower body first, then your chest.
- C. As you hold onto the trapeze, lift your hips off the bed.
- D. Let me roll you as if you were a log.
Correct Answer: D
Rationale: Log-rolling maintains spinal alignment during turning post-laminectomy, preventing strain on the surgical site and reducing complications like nerve damage or incision dehiscence.
The client diagnosed with cervical disk degeneration has undergone a laminectomy. Which interventions should the nurse implement?
- A. Position the client prone with the knees slightly elevated.
- B. Assess the client for difficulty speaking or breathing.
- C. Measure the drainage in the Jackson Pratt bulb every day.
- D. Encourage the client to postpone the use of narcotic medications.
Correct Answer: B
Rationale: Cervical laminectomy risks airway or neurological complications; assessing speech and breathing is critical. Prone positioning is inappropriate, JP drainage is routine, and delaying narcotics is unsafe.
When the nurse assesses the client, which finding is the best indication that the shoulder has been dislocated?
- A. The client is experiencing intense pain.
- B. The client is receiving intense pain.
- C. The client is hesitant to move the arm.
- D. The affected arm is longer than the other.
Correct Answer: D
Rationale: A dislocated shoulder often results in the affected arm appearing longer due to the humeral head being displaced from the glenoid fossa, altering the arm's alignment. Pain and hesitancy to move are common but less specific, and 'receiving intense pain' is a typographical error.