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 D

Explanation

Choice A reason:
Dysuria, or painful urination, is a common symptom of cystitis and indicates inflammation of the bladder, often caused by a urinary tract infection (UTI). While it is a symptom to monitor, it does not necessarily indicate progression of the infection.

Choice B reason:
An increased frequency of urination can be a symptom of cystitis due to irritation of the bladder lining. However, like dysuria, it is a common symptom of a UTI and may not signify that the infection is worsening.

Choice C reason:
Pyuria, the presence of white blood cells in the urine, and hematuria, the presence of blood in the urine, are both indicators of inflammation and infection. These symptoms can occur with cystitis but are also not specific to the progression of the infection.

Choice D reason:
Fever is a systemic response to infection and can indicate that a UTI, such as cystitis, is worsening or spreading, possibly to the kidneys, which is known as pyelonephritis. Monitoring for fever is important because it may necessitate more aggressive treatment, such as antibiotics, and possibly hospitalization if the infection is severe.

A. "Please share the joke with me." B. "You're laughing. Tell me what's happening." C. "Why are you laughing?" D. "I don't think I said anything funny."

Correct Answer is B

Explanation

Choice A Reason:
Asking the client to share the joke may imply that the nurse believes the client is laughing at a joke, which may not be the case. It's important to recognize that uncontrollable laughter can be a symptom of schizophrenia and not necessarily a response to humor.

Choice B Reason:
This response is open-ended and nonjudgmental, inviting the client to explain their behavior without making assumptions. It allows the client to share their experience, which could be related to an internal stimulus such as a hallucination or simply a response they cannot control.

Choice C Reason:
Asking "Why are you laughing?" could be perceived as confrontational or accusatory. It might make the client feel defensive or misunderstood, especially if the laughter is a symptom of their condition and not something they are doing voluntarily.

Choice D Reason:
Saying "I don't think I said anything funny" focuses on the nurse's perspective rather than the client's experience. It could inadvertently dismiss the client's behavior as inappropriate or unjustified, which is not supportive in a therapeutic relationship.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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