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 D

Explanation

Choice A rationale
Informing the charge nurse is an important step, but it is not the immediate action. The nurse should first assess the situation before escalating it.
Choice B rationale
Applying a dressing under the client’s nose might help manage the drainage, but it does not address the underlying issue. The drainage could be cerebrospinal fluid (CSF), which is a serious condition that needs immediate attention.
Choice C rationale
Checking the client’s temperature is a general assessment and does not directly relate to the symptom of clear nasal drainage.
Choice D rationale
Testing the drainage for glucose is the correct action. Clear nasal drainage after a basal skull fracture could be a sign of a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help confirm if it’s CSF34.

A. Pancreatitis B. Peptic ulcer disease C. Inflammatory bowel disease D. Gastrointestinal malignancy E. Diverticulosis F. Gallbladder disease G. Hypothyroidism

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale
Pancreatitis can lead to gastrointestinal bleeding. Inflammation of the pancreas can cause damage to the organ’s blood vessels, leading to bleeding. This can be a serious complication of pancreatitis.
Choice B rationale
Peptic ulcer disease is a common cause of gastrointestinal bleeding. Ulcers are sores that develop on the lining of the stomach, upper small intestine, or esophagus. When these ulcers erode into blood vessels, bleeding can occur.
Choice C rationale
Inflammatory bowel disease (IBD), which includes conditions like Crohn’s disease and ulcerative colitis, can cause ulcers in the digestive tract. These ulcers can bleed, leading to gastrointestinal bleeding.
Choice D rationale
Gastrointestinal malignancy, or cancer, can cause gastrointestinal bleeding. Tumors can erode into blood vessels or cause ulcers that bleed.
Choice E rationale
Diverticulosis involves the formation of small pouches in the wall of the digestive tract. These pouches can bleed, leading to gastrointestinal bleeding.
Choice F rationale
Gallbladder disease typically does not cause gastrointestinal bleeding. The gallbladder stores bile, a fluid produced by the liver to digest fats. While gallstones and inflammation of the gallbladder are common, they do not usually lead to gastrointestinal bleeding.
Choice G rationale
Hypothyroidism, a condition in which the thyroid gland does not produce enough thyroid hormone, is not typically associated with gastrointestinal bleeding. Symptoms of hypothyroidism can include fatigue, weight gain, and depression, but not gastrointestinal bleeding.

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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?

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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?