Extract:

Question 1 of 5

A nurse is assisting with the care of a client who is postoperative following a laminectomy. Which of the following actions should the nurse take?

A. Encourage the client to lie flat on their back for 24 hr.B. Monitor the client for urinary retention.C. Instruct the client to perform leg exercises every 4 hr.D. Apply a heating pad to the surgical site.

Correct Answer: B

Rationale: Urinary retention is a risk post-laminectomy due to spinal anesthesia or pain, requiring monitoring. Flat positioning varies, leg exercises are more frequent, and heat isn't standard.

Question 2 of 5

A nurse is caring for a client who has a new prescription for prednisone. Which of the following actions should the nurse take?

A. Instruct the client to stop the medication if they develop a headache.B. Monitor the client for signs of hyperglycemia.C. Administer the medication via rapid IV push.D. Check the client's blood pressure prior to administration.

Correct Answer: B

Rationale: Prednisone, a corticosteroid, can cause hyperglycemia, requiring monitoring (e.g., glucose levels). Headaches don't warrant stopping, it's oral or slow IV, and BP is checked as needed.

Question 3 of 5

A nurse is caring for a client who has a new prescription for spironolactone. Which of the following actions should the nurse take?

A. Instruct the client to increase potassium-rich foods.B. Monitor the client for signs of hyperkalemia.C. Administer the medication via rapid IV push.D. Check the client's blood glucose level prior to administration.

Correct Answer: B

Rationale: Spironolactone, a potassium-sparing diuretic, risks hyperkalemia, requiring monitoring (e.g., potassium levels). Potassium intake should be limited, it's oral, and glucose isn't affected.

Question 4 of 5

A nurse is assisting with the care of a client who is postoperative following a craniotomy. Which of the following actions should the nurse take?

A. Keep the head of the bed flat.B. Monitor the client for signs of increased intracranial pressure.C. Instruct the client to cough forcefully every 2 hr.D. Apply a warm compress to the surgical site.

Correct Answer: B

Rationale: Increased intracranial pressure is a risk post-craniotomy, requiring monitoring (e.g., pupil changes). Elevation, not flat positioning, gentle coughing, and no heat are standard.

Question 5 of 5

A nurse is assisting with the care of a client who is receiving a continuous IV infusion of normal saline. Which of the following actions should the nurse take?

A. Change the IV site every 24 hr.B. Monitor the client for signs of phlebitis.C. Flush the IV line with heparin every 4 hr.D. Administer the infusion at a rate of 100 mL/hr.

Correct Answer: B

Rationale: Phlebitis (e.g., redness, pain) is a risk with IV infusions, requiring monitoring. Site changes are every 72-96 hr, heparin isn't routine, and rate depends on orders.