A nurse is caring for a client who has arrived in the postoperative unit following a laminectomy and spinal fusion. Which action should the nurse take?

Assist the client to turn, having them grasp the side rails.

Maintain strict bedrest for 48 hours postoperatively.

Assess the client's pain level and administer pain medication as needed.

Place the client in the prone position.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Assisting the client to turn by having them grasp the side rails is not recommended immediately following a laminectomy and spinal fusion. This action could place undue stress on the surgical site and potentially disrupt the healing process. Postoperative care typically involves minimizing movement of the spine to prevent complications.

Choice B reason:

Maintaining strict bedrest for 48 hours postoperatively is not a current standard of care following a laminectomy and spinal fusion. Early ambulation, as tolerated, is encouraged to promote circulation and prevent complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE).

Choice C reason:

Assessing the client's pain level and administering pain medication as needed is a critical nursing intervention postoperatively. Effective pain management is essential for promoting patient comfort, facilitating early mobilization, and preventing complications. Pain assessment and management should be tailored to the individual's needs and carried out with regular monitoring.

Choice D reason:

Placing the client in the prone position is not typically advised following a laminectomy and spinal fusion, as it may put pressure on the surgical site and cause discomfort. The preferred position is usually on the back or occasionally on the side with proper support, depending on the surgeon's protocol and the client's comfort.

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Correct Answer is B

Explanation

Choice A Reason

An oral temperature of 100.6°F may indicate that the client still has a fever, which could suggest ongoing infection. However, temperature alone is not the most reliable indicator of the effectiveness of antibiotic therapy, as it can be influenced by various factors.

Choice B Reason

Pulse oximetry measures the oxygen saturation of the blood, which is a direct indicator of respiratory function. For a client with pneumonia, an improvement in oxygen saturation to 98% on room air is a strong sign that the lungs are effectively exchanging gases and that the pneumonia is resolving. This would be a clear indication that the amoxicillin is effective.

Choice C Reason

An increased neutrophil count is a sign of acute infection, but it does not directly measure the effectiveness of the antibiotic therapy. Neutrophil counts can remain elevated even as the infection is resolving, so they are not the best sole indicator of therapeutic effectiveness.

Choice D Reason

Adequate urine output is important for overall health and indicates good kidney function, but it is not a direct measure of the effectiveness of antibiotic therapy for pneumonia. Urine output does not reflect the respiratory status or the resolution of lung infection.

A. Check blood glucose levels prior to exercising. B. Signs and symptoms of hypoglycemia. C. Weight control is necessary for this disease. D. Decrease fiber and protein in the diet. E. Obtain eye examinations every 3 months.

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

Explanation

Choice A Reason
Monitoring blood glucose levels before exercise is crucial for individuals with Type 2 diabetes. Exercise can lower blood glucose levels, and it's important to ensure they are not too low before starting, which could lead to hypoglycemia during physical activity. The patient should be taught how to check their glucose and understand their target ranges.

Choice B Reason
Recognizing the signs and symptoms of hypoglycemia is essential for all individuals with diabetes, especially those on medications that can lower blood glucose levels. Symptoms may include shakiness, sweating, confusion, and in severe cases, loss of consciousness. Patients should know how to respond to these symptoms promptly.

Choice C Reason
Weight control through diet and exercise is a fundamental part of managing Type 2 diabetes. A BMI of 28 falls into the overweight category, and reducing weight can help improve insulin sensitivity and blood glucose control. The patient should receive guidance on healthy eating and physical activity tailored to their needs.

Choice D Reason
Decreasing fiber and protein in the diet is not recommended for individuals with Type 2 diabetes. In fact, a diet high in fiber can help control blood sugar levels, and adequate protein intake is important for overall health. Patients should be encouraged to consume a balanced diet with sufficient fiber and protein.

Choice E Reason
While regular eye examinations are important for individuals with diabetes, obtaining them every 3 months is not typically necessary unless there is an existing eye condition that requires close monitoring. Generally, an annual eye exam is recommended to check for diabetes-related eye complications.

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A nurse is caring for a client who has arrived in the postoperative unit following a laminectomy and spinal fusion. Which action should the nurse take?

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How would the nurse best evaluate the effectiveness of drug therapy for a client diagnosed with pneumonia being treated with amoxicillin?

Correct Answer is B

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

Explanation

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