A nurse is caring for a client who has undergone lumbar spinal surgery for degenerative disk disease. Which of the following interventions should the nurse identify as the priority?
Inspect the client's surgical dressing for clear drainage.
Log roll the client every 2 hr.
Auscultate the client for bowel sounds every shift.
Monitor the client's temperature.
The Correct Answer is B
Rationale:
A. Inspect the client's surgical dressing for clear drainage: Monitoring the surgical site is important for identifying CSF leakage or infection, but it is not the top priority. While drainage should be assessed regularly, preserving spinal alignment takes precedence immediately post-op.
B. Log roll the client every 2 hr: Maintaining spinal alignment is the priority following lumbar spinal surgery to prevent injury to the surgical site and spinal cord. Log rolling ensures the spine remains in neutral alignment and reduces strain on healing tissues.
C. Auscultate the client for bowel sounds every shift: Bowel function should be monitored, especially due to anesthesia and immobility, but it is not the most urgent concern compared to maintaining spinal integrity postoperatively.
D. Monitor the client's temperature: Monitoring for signs of infection is essential, but it is not the highest priority in the immediate postoperative period. Preventing spinal movement that could cause neurologic damage is more urgent at this stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Emergent: Severe chest pain is potentially life-threatening and may indicate conditions like myocardial infarction. Immediate intervention is required to preserve life, making this an emergent priority in triage.
B. Nonurgent: This category applies to clients with minor issues that do not pose an immediate health threat. Severe chest pain would not fall here due to the risk of cardiac events.
C. Urgent: Urgent cases require prompt but not immediate care. While serious, this category is for stable clients who can wait briefly unlike someone with potential cardiac compromise.
D. Expectant: This category is used for clients whose injuries are so severe that survival is unlikely, even with treatment. A client with chest pain could still benefit from immediate care and is not considered expectant.
Correct Answer is C
Explanation
Rationale:
A. Communicate information about the new policy to nursing staff: This occurs after the policy is developed and approved. It is important for implementation but is not the first step in policy development.
B. Create options for implementing the new policy: This step follows initial research and policy design. It cannot be done until there is a clear understanding of requirements and goals.
C. Research the requirements of accrediting agencies that are related to the new policy: This is the first step to ensure the policy aligns with regulatory standards and evidence-based practices. It provides a foundation for developing relevant and compliant guidelines.
D. Review feedback from nursing staff to determine the effectiveness of the new policy: This is part of the evaluation phase, which happens after the policy has been implemented and trialed.
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