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?

Based on the provided exhibits, the client is most likely experiencingBacterial Meningitis. This is indicated by symptoms such as severe headache, fever, sensitivity to light, nuchal rigidity, and the presence of Neisseria meningitidis in the cerebrospinal fluid with elevated white blood cell count and lactic acid levels.

The two actions the nurse should take to address this condition are:

1. Anticipate administering antibiotic therapy- This is crucial as the client’s culture and sensitivity test indicates the presence of Neisseria meningitidis, which requires antibiotic treatment.
2. Place the client on droplet precautions- Since Neisseria meningitidis can be spread through respiratory droplets, it is important to implement droplet precautions to prevent the spread of infection.

The two parameters the nurse should monitor to assess the client’s progress are:

1. Level of consciousness- Monitoring for changes in the client’s level of consciousness can indicate the effectiveness of the treatment and the progression of the disease.
2. Increased intracranial pressure- Signs of increased intracranial pressure can include changes in vital signs, level of consciousness, and the presence of headache or vomiting. Monitoring these signs is important in the management of bacterial meningitis.

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.