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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Protective isolation is not routinely required for clients following scoliosis repair unless there is an underlying infection risk.
B. A PCA pump may be used for pain control, but it is not specific to post-scoliosis repair care.
C. Keeping the head of the bed at 30° is not required; positioning should focus on spinal alignment.
D. Log rolling the client every 4 hours is essential to maintain spinal alignment, prevent complications, and ensure safety following Harrington rod instrumentation.
Correct Answer is D
Explanation
A. Vitamin B is a group of vitamins that play various roles in the body, including energy metabolism and nerve function. While it is important for overall health, it is not specifically known for wound healing.
B. Vitamin E is an antioxidant that helps protect cells from damage. While it is important for overall health, it is not specifically known for wound healing.
C. Folate (also known as vitamin B9) is essential for DNA synthesis and repair, as well as cell division. It is important for overall health, but it is not as directly associated with wound healing as vitamin C.
D. Correct. Vitamin C, also known as ascorbic acid, is essential for collagen synthesis, which is a key component of wound healing. It helps in the formation of scar tissue and the repair of damaged skin.
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