A nurse is caring for a client who is postoperative following a craniotomy for a tumor removal and has a surgical drain in place. Which of the following actions should the nurse take?

Provide the client with clear liquids after 8 hr postoperative.

Apply a warm, moist compress if the client develops periorbital edema.

Measure the surgical drain output every 12 hr.

Maintain the client's head in a midline, neutral position.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Provide the client with clear liquids after 8 hr postoperative: Postoperative diet advancement is based on return of the gag reflex and swallowing ability, not on a set time frame. Starting clear liquids too soon can increase the risk of aspiration.

B. Apply a warm, moist compress if the client develops periorbital edema: Cold compresses, not warm, are recommended in the first 24–48 hours to reduce swelling. Warm compresses may increase blood flow and worsen edema, especially near the surgical site.

C. Measure the surgical drain output every 12 hr: Drain output should be monitored at least every 1–2 hours initially to detect signs of increased bleeding or cerebrospinal fluid leakage. Waiting 12 hours may delay recognition of serious complications.

D. Maintain the client's head in a midline, neutral position: Keeping the head in a neutral position facilitates venous drainage and helps prevent an increase in intracranial pressure. This is a priority intervention following craniotomy to support cerebral perfusion.

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Correct Answer is B

Explanation

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.

A. Tracheal deviation B. Petechial rash C. Clay-colored stools D. Peripheral edema

Correct Answer is B

Explanation

Rationale:

A. Tracheal deviation: Tracheal deviation is typically associated with conditions such as tension pneumothorax or large pleural effusions, not idiopathic thrombocytopenia. It reflects a shift in intrathoracic pressure, not a bleeding or platelet issue.

B. Petechial rash: Idiopathic thrombocytopenia involves a low platelet count, impairing clot formation and leading to bleeding under the skin. A petechial rash tiny, pinpoint red or purple spots is a hallmark symptom caused by capillary hemorrhages due to thrombocytopenia.

C. Clay-colored stools: Clay-colored stools are usually linked to biliary obstruction or liver disorders that interfere with bile excretion. This symptom is unrelated to platelet levels or idiopathic thrombocytopenia.

D. Peripheral edema: Peripheral edema generally results from fluid retention due to heart failure, kidney disease, or liver dysfunction. It is not a common finding in clients with idiopathic thrombocytopenia, which primarily affects bleeding and bruising.

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