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 A
Explanation
Choice A rationale
The production of black colored sputum in a client with a major burn injury could indicate inhalation injury, which is a serious complication associated with burns. Inhalation injury can lead to respiratory failure, a leading cause of death in patients with burn injuries.
Choice B rationale
While large blistered areas over the chest indicate a significant burn injury, they are not immediately life-threatening. These areas will require wound care and monitoring for infection.
Choice C rationale
Edema at the burn site is a common response to burn injuries. It is caused by an increase in capillary permeability following the injury. While it needs to be monitored, it is not the highest priority.
Choice D rationale
Decreased sensation over the burn areas could indicate a deep partial-thickness or full-thickness burn. While this is a serious condition that will require treatment, it is not as immediately life-threatening as an inhalation injury.
Correct Answer is B
Explanation
Choice A rationale
A 33-year-old with burns to the back and shoulders. While this patient’s injuries are serious, they are not immediately life-threatening. The back and shoulders are not vital areas, and while pain management and wound care will be necessary, this patient’s situation is not as urgent as others.
Choice B rationale
A 32-year-old with burns on the hands and face. This patient should be attended to first. Burns on the hands and face are more serious due to the high risk of infection and the potential for complications such as impaired breathing if the airway swells or becomes blocked due to the burns. Immediate treatment can help to prevent these complications.
Choice C rationale
A 42-year-old with burns on both legs. While these burns are serious, they are not immediately life-threatening. The patient will need pain management and wound care, and may have mobility issues, but their vital organs are not directly impacted by the burns.
Choice D rationale
A 25-year-old with a burn on the left arm. This patient, while in need of treatment, is not the highest priority. A burn on the arm, while painful and requiring treatment, is not as potentially serious or life-threatening as burns to the face, hands, or major portions of the body.
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