Unit 2: Iggy 9th Practice Questions

Question 1

5. A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this clients postoperative instructions?
   a. Only lift items that are 10 pounds or less.
   b. Wear your brace whenever you are out of bed.
   c. You must remain in bed for 3 weeks after surgery.
   d. You are prescribed medications to prevent rejection.

Answer 1

b. Wear your brace whenever you are out of bed.

Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client should not lift anything. The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.

Question 2

6. A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should urgently alert the nurse to communicate with the health care provider?
   a. Auscultated stridor
   b. Weak pedal pulses
   c. Difficulty swallowing
   d. Inability to shrug shoulders

Answer 2

ANS: A
Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.

Question 3

7. A nurse assesses a client with a spinal cord injury at level T5. The client’s blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?
   a. Initiate oxygen via a nasal cannula.
   b. Place the client in a supine position.
   c. Palpate the bladder for distention.
   d. Administer a prescribed beta blocker.

Answer 3

ANS: C
The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.