Nokea
Which of the ff. problems during the immediate postoperative course ff. lumbar microdiskectomy should be reported to the physician immediately?
- A. Incisional pain
- B. Inability to move affected leg
- C. Two-inch area of bleeding on dressing
- D. Muscle spasm of affected
Correct Answer: B
Rationale: The correct answer is B because the inability to move the affected leg post lumbar microdiskectomy could indicate a serious complication like nerve damage or blood clot. This would require immediate medical attention to prevent further complications. Incisional pain (A) is common and can be managed with pain medication. A two-inch area of bleeding on the dressing (C) is concerning but can be managed with proper wound care unless it is excessive. Muscle spasm (D) is also common postoperatively and can be managed with medications or physical therapy.
You may also like to solve these questions
A client who suffered a vehicular accident a few days ago is in skeletal traction. Which nursing action would BESt promote INDEPENDENCE for this patient?
- A. tell the client to call for an analgesic before the pain felt becomes severe
- B. encourage the patient to do leg exercises within the limits of his traction
- C. provide an overhead trapeze for client use on the Balkan frame
- D. provide skin care to prevent skin breakdown
Correct Answer: B
Rationale: The correct answer is B because encouraging the patient to do leg exercises within the limits of his traction promotes independence by maintaining muscle strength and mobility. This helps prevent muscle atrophy and promotes circulation. Choice A focuses on pain management but does not directly promote independence. Choice C provides assistance but does not actively involve the patient in self-care. Choice D is important for overall care but does not directly promote independence through active patient involvement.
Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply
- A. Affected area appears to enlarge
- B. Red streaks extend up the arm or leg
- C. Additional lymph nodes become
- D. Liver and spleen become enlarged
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Lymphangitis is an inflammation of lymphatic vessels.
2. If the affected area appears to enlarge, it indicates possible worsening or spreading of the infection.
3. Nurse should notify the physician for further evaluation and treatment.
4. Red streaks extending up the arm or leg (B) are common signs of lymphangitis, not necessarily requiring immediate physician notification.
5. Additional lymph nodes becoming (C) is a normal response to infection and may not warrant immediate physician notification.
6. Liver and spleen enlargement (D) are not directly related to lymphangitis and do not require immediate notification.
A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heart burn. Which nursing instruction should the nurse provide?
- A. “Take ferrous sulfate and the antacid together.”
- B. “Take ferrous sulfate and the antacid at least 2 hours apart.”
- C. “Avoid taking an antacid altogether.”
- D. “Take ferrous sulfate and the antacid at least 1 hour apart.”
Correct Answer: B
Rationale: The correct answer is B: "Take ferrous sulfate and the antacid at least 2 hours apart."
Rationale:
1. Iron absorption is decreased in the presence of antacids due to decreased gastric acidity.
2. Antacids can bind to iron and reduce its absorption.
3. Taking them 2 hours apart allows for optimal iron absorption without interference from the antacid.
4. Taking them together (choice A) would decrease iron absorption.
5. Avoiding antacids altogether (choice C) may not be necessary if spaced apart appropriately.
6. Taking them 1 hour apart (choice D) may still lead to decreased iron absorption due to antacid interference.
A client has possible malignancy of the colon, and surgery is scheduled. The rationale for administering Neomycin preoperatively is to:
- A. Prevent infection postoperatively
- B. Eliminate the need for preoperative enemas
- C. Decreased and retard the growth of normal bacteria in the intestines
- D. Treat cancer of the colon
Correct Answer: C
Rationale: The correct answer is C because Neomycin is given preoperatively to decrease and retard the growth of normal bacteria in the intestines. This helps reduce the risk of infection during surgery by minimizing the number of bacteria present in the colon. Options A, B, and D are incorrect because Neomycin is not given to prevent infection postoperatively, eliminate the need for preoperative enemas, or treat cancer of the colon. The main purpose of administering Neomycin in this scenario is to create a sterile surgical field by reducing the normal flora in the intestines.
Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
- A. Hand bell and extra bed linen
- B. Footboard and splint
- C. Sandbag and trochanter rolls
- D. Suction machine and gloves
Correct Answer: C
Rationale: Step 1: Mr. Franco's condition suggests he may need support and positioning.
Step 2: Sandbags provide stability and trochanter rolls prevent hip rotation.
Step 3: These help prevent pressure ulcers and maintain proper body alignment.
Step 4: Hand bell and bed linen are not essential for Mr. Franco's immediate care.
Step 5: Footboard and splint may not be relevant to his specific condition.
Step 6: Suction machine and gloves are important but not as crucial as positioning aids for Mr. Franco.
Summary: Choice C is correct as it directly addresses Mr. Franco's needs for support and positioning, while the other choices are less relevant or not as essential in this context.