A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take?
Log roll the client every 2 hr.
Expect clear drainage on the spinal dressing.
Assist the client to sit upright in a chair for 4 hr at a time.
Elevate the client's legs when he is sitting in a chair.
The Correct Answer is A
A. This technique helps to prevent pressure ulcers and assists in maintaining proper spinal alignment, which is essential after such a surgery.
B. Clear drainage on the spinal dressing is not typically expected and could indicate an infection or other complication.
C. Assisting the client to sit upright in a chair for extended periods is not standard practices immediately following spinal fusion, as these actions may put undue stress on the spine during the critical initial healing phase.
D. Elevating the client's legs while sitting are not standard practices immediately following spinal fusion, as these actions may put undue stress on the spine during the critical initial healing phase
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Assessing the client's pain level is crucial, especially before physical therapy, as pain can affect participation and compliance with therapy. If the client is experiencing pain, appropriate pain management measures should be implemented before PT to optimize participation and comfort.
A. The nurse should educate the client on proper body mechanics and positions to avoid during physical therapy to promote safe movement and prevent complications. However, this is not a priority.
C. While morning care is important for maintaining hygiene and comfort, it may not be the priority at this specific time, especially if the client is scheduled for physical therapy soon.
D. Encouraging full weight bearing immediately postoperative may not be appropriate, as the surgical site needs time to heal and regain strength.
Correct Answer is C
Explanation
C. The client’s laboratory values are all within normal range. It is therefore, safe for the nurse to proceed with preparation for theatre.
A. Notifying the provider immediately is a preferred action in the case of any abnormal laboratory values of concern.
B. Questioning on the recent infection would be relevant if the white blood count is elevated which is not the case in this scenario.
D. The client’s hemoglobin is within normal range and therefore, no need for transfusion at this point.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.