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:
An increase in urine output can be a sign of improved kidney function or the effect of medications, but it is not a direct indicator of reduced cardiac workload. Atenolol, a beta-blocker, primarily reduces the heart rate and myocardial oxygen demand, not urine output.

Choice b reason:
Less dyspnea with activity suggests improved cardiovascular efficiency, but it is not a specific measure of cardiac workload. Dyspnea can be influenced by respiratory conditions and is not solely determined by cardiac function.

Choice c reason:
A blood pressure of 120/80 mmHg is considered optimal for most adults and indicates good control of hypertension. However, it does not specifically reflect the cardiac workload, which is more directly affected by heart rate and myocardial oxygen demand.

Choice d reason:
A heart rate of 65 per minute is a clear indicator that atenolol is effective in reducing cardiac workload. Atenolol decreases the heart rate, which in turn reduces myocardial oxygen demand and the overall workload on the heart. This is particularly important for patients with unstable angina, where reducing the heart's workload can prevent angina attacks and potential myocardial infarction.

A. Apply cool compresses to the affected limb every six hours. B. Place a soft pillow under the affected knee. C. Promote bedrest for 24 hours. D. Encourage increased fluid intake.

Correct Answer is D

Explanation

Choice A Reason
Applying cool compresses to the affected limb can help reduce swelling and provide pain relief. However, it's important to follow the surgeon's specific postoperative orders, as the application of cold can vary depending on the surgical technique and patient's condition.

Choice B Reason
Placing a soft pillow under the knee is not recommended after total knee replacement surgery. This position can lead to decreased range of motion and contractures. The knee should be kept in a more extended position to promote healing and mobility.

Choice C Reason
Promoting bedrest for an extended period is not typically advised following knee replacement surgery. Early mobilization is important to prevent complications such as deep vein thrombosis and to encourage circulation and healing. The duration of bedrest should be as per the surgeon's protocol.

Choice D Reason
Encouraging increased fluid intake is important after surgery to prevent dehydration, promote kidney function, and ensure adequate blood volume and circulation. Proper hydration is essential for healing and can help with the metabolism of medications used during and after surgery.

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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 D

Explanation

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