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
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Related Questions
Correct Answer is C
Explanation
C. Asking the client to wiggle their toes assesses motor function and nerve integrity. In a neurovascular assessment, intact nerve function is crucial, as impaired nerve function can manifest as weakness or paralysis.
A. This technique assesses the circulation in the lower extremity by checking for the presence, strength, and symmetry of the pulse. However, it assesses for vascular component proximal to the fracture.
B. Edema in the calf muscle is mostly used as a marker for deep venous thrombosis. Although it can affect circulation. It may be a late sign.
D. Significant differences in thigh circumference between the affected and unaffected limb may indicate vascular compromise or other issues. This is however, a late sign of vascular compromise.
Correct Answer is C
Explanation
C. Maintaining immobilization and alignment of the fractured bone is essential for allowing the bone to heal properly. Immobilization prevents further injury and displacement of the fracture fragments, while proper alignment ensures optimal bone healing and functional outcomes.
A. Optimal nutrition and hydration may not be the highest priority compared to other interventions that directly address the fracture management and functional healing.
B. Providing relief from pain and discomfort is crucial for the client's comfort and well-being, but it may not be the highest priority in achieving functional healing.
D. Promoting independence in activities of daily living is important for the client's overall well-being and quality of life, but it may not be the highest priority immediately after a fracture.
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