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.

Answer and Explanation

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.

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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.

A. Areas around pins are dry. B. Crusts around pins. C. Purulent drainage around pins. D. Absence of pain at the site.

Correct Answer is C

Explanation

Choice A rationale
Areas around pins being dry is a normal finding and does not need to be reported.
Choice B rationale
Crusts around pins are also a normal finding as they are usually dried exudate and do not indicate an infection.
Choice C rationale
Purulent drainage around pins is a sign of infection. This should be reported to the unit care coordinator immediately as it may require antibiotic treatment.
Choice D rationale
Absence of pain at the site is a normal finding and does not need to be reported.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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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?