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.

Answer and Explanation

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

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Correct Answer is D

Explanation

D. Difficulty or inability to abduct (raise out to the side) the arm at the shoulder is a classic finding in rotator cuff injuries, particularly in cases of significant tears or severe inflammation. This limitation in shoulder movement can be due to pain, weakness, or mechanical impingement caused by the injured rotator cuff.

A. The drop arm test is a physical examination maneuver used to assess for rotator cuff tears. In a negative drop arm test, the patient is able to slowly lower their arm from an abducted position (out to the side) to their side without significant pain or weakness. A negative test suggests that there may not be a complete tear of the rotator cuff.

B. Alteration in the contour of the shoulder joint could indicate various shoulder pathologies, including rotator cuff injuries. However, it is a nonspecific finding and can occur with other shoulder conditions as well.

C. Tinel's sign is a test used to assess for nerve compression or irritation. While it can be positive in conditions such as carpal tunnel syndrome, it is not typically associated with rotator cuff injuries.

A. Venous thromboembolism B. Fluid and electrolyte imbalance C. Impaired surgical wound healing D. Hypovolemic shock

Correct Answer is A

Explanation

A. Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant concern following knee replacement surgery due to the increased risk of blood clot formation associated with immobility and surgery. Limited mobility can predispose the patient to stasis of blood flow, which increases the risk of VTE.

B. While fluid and electrolyte imbalance can occur postoperatively, especially if the patient experiences complications such as excessive bleeding or fluid shifts, limited mobility alone is less likely to directly lead to this complication as a priority.

C. Limited mobility can potentially impact surgical wound healing by delaying the resolution of edema, impairing circulation, and increasing the risk of infection. However, this complication may not be as immediate or life-threatening as others on the list.

D. Hypovolemic shock, characterized by inadequate tissue perfusion due to decreased circulating blood volume, is a severe complication that can result from significant blood loss. While bleeding can occur postoperatively, it is less common as a complication of knee replacement surgery, especially within the first few days.

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A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is assessing a client who reports shoulder pain. Which of the following findings by the nurse indicates rotator cuff injury?

Correct Answer is D

Explanation

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which potential complication should the nurse identify as a priority for this patient?

Correct Answer is A

Explanation

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