A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take?
Position the client in a high-Fowler's position if clear drainage is noted on the dressing
Monitor sensory perception of the lower extremities.
Assist the client into a knee-chest position to manage postoperative discomfort.
Maintain strict bed rest for the first 48 hr postoperative.
The Correct Answer is B
A. Positioning the client in a high-Fowler's position if clear drainage is noted on the dressing is not a specific intervention for a laminectomy with spinal fusion. The nurse should follow the surgeon's specific postoperative orders regarding positioning and wound care.
B. Monitoring sensory perception of the lower extremities is a crucial nursing intervention after a laminectomy with spinal fusion. This is to assess for any signs of neurovascular compromise or nerve damage.
C. Assisting the client into the knee-chest position to manage postoperative discomfort is not a recommended position after a laminectomy with spinal fusion. The nurse should follow the surgeon's specific postoperative orders regarding positioning.
D. Maintaining strict bed rest for the first 48 hours postoperative is not typically indicated after a laminectomy with spinal fusion. Early mobilization and ambulation are often encouraged to prevent complications and promote recovery. The nurse should follow the surgeon's specific postoperative orders regarding activity and mobility.
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Related Questions
Correct Answer is A
Explanation
A. Hematuria: This is the correct answer. Hematuria, which is the presence of blood in the urine, can be a common complication of pelvic fractures. This occurs due to the potential injury to the bladder or other structures within the pelvis. Monitoring for hematuria is crucial in assessing potential internal injuries and ensuring appropriate management.
B. Impaired taste: Impaired taste is not typically associated with pelvic fractures. It is more likely related to conditions involving the sense of taste or other unrelated factors. It is not a common complication of pelvic fractures.
C. Diarrhea: Diarrhea is not a common complication of pelvic fractures. It is more likely to be caused by gastrointestinal issues, infections, dietary factors, or other medical conditions. It is not directly related to pelvic fractures or their complications.
D. Increased thirst: Increased thirst is not a common complication of pelvic fractures. It may be related to various factors such as dehydration, certain medical conditions like diabetes, or side effects of medications. It is not a direct consequence of pelvic fractures or their associated complications.
Correct Answer is C
Explanation
A. Twisting at the waist while lifting or moving an object can strain the back muscles and potentially lead to injury. The nurse should advise against this.
B. Relaxing the abdominal muscles while lifting an object can lead to inadequate support for the spine, potentially causing further strain or injury. The nurse should instruct the client to engage the abdominal muscles for stability.
C. Correct. Bending at the knees when picking up an object helps distribute the weight more evenly and reduces strain on the back muscles. This is a safe and recommended technique for lifting.
D. Holding an object away from the body while lifting it can increase the strain on the back muscles. The client should be advised to keep the object close to their body for better support and balance.
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