A nurse is assisting with the plan of care for a client who is 1 day postoperative following spinal fusion.
Which of the following interventions should the nurse include in the plan?
Assist the client to sit upright in a chair for 4 hr at a time.
Expect clear drainage on the spinal dressing.
Elevate the client’s legs when he is lying on his side.
Log roll the client every 2 hr.
The Correct Answer is D
Choice A rationale
Assisting the client to sit upright in a chair for 4 hr at a time is not recommended postoperatively following spinal fusion. This could put undue stress on the surgical site and potentially lead to complications.
Choice B rationale
Expecting clear drainage on the spinal dressing is not accurate. Any drainage from the surgical site should be closely monitored for signs of infection, but clear drainage is not typically expected.
Choice C rationale
Elevating the client’s legs when he is lying on his side is not a specific intervention related to postoperative care following spinal fusion.
Choice D rationale
Log rolling the client every 2 hr is the correct intervention. This technique is used to maintain proper alignment and prevent undue stress on the surgical site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A DNR prescription does not mean that the patient will only receive pain medication for their treatments. A DNR order simply means that if the patient’s heart stops beating or they stop breathing, medical staff will not attempt resuscitation3.
Choice B rationale
A DNR prescription does not necessarily limit a patient’s current treatment regimen. It only specifies that CPR will not be performed in the event of cardiac or respiratory arrest. Other treatments can still be provided based on the patient’s wishes and the medical team’s recommendations3.
Choice C rationale
A DNR prescription allows a patient to continue with their current treatment regimen. The DNR order only comes into effect if the patient’s heart stops or they stop breathing3.
Choice D rationale
While a DNR prescription may limit the ability to receive invasive procedures in the event of cardiac or respiratory arrest, it does not limit other forms of treatment. The patient can still receive treatments that align with their goals of care3.
Correct Answer is A
Explanation
Choice A rationale
Furosemide is a diuretic, or water pill, that helps your body get rid of extra salt and water. It can cause you to lose too much potassium, a mineral that helps your nerves, muscles, and organs work normally. So, it’s important to eat foods that are high in potassium, such as bananas, oranges, tomatoes, beans, and spinach.
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