A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?

Oral temperature of 37.2° C (99° F)

Clear drainage on the dressings

Drain output 75 mL in 4 hr

Decreased bowel sounds in all quadrants of the abdomen

Answer and Explanation

The Correct Answer is B

Rationale:
A. Oral temperature of 37.2° C (99° F): This is a normal postoperative temperature and does not indicate infection or any other complication. Mild elevations in temperature are expected after surgery.

B. Clear drainage on the dressings: Clear drainage, particularly if it is watery and not tinged with blood, may indicate cerebrospinal fluid (CSF) leakage. This is a serious complication of spinal surgery and requires immediate evaluation to prevent infection and further neurological issues.

C. Drain output 75 mL in 4 hr: This amount of drainage is within normal limits for the early postoperative period, depending on the surgeon's parameters. It is not inherently concerning unless it becomes excessive or has abnormal characteristics.

D. Decreased bowel sounds in all quadrants of the abdomen: Decreased bowel activity is common after surgery due to anesthesia and immobility. It is expected in the immediate postoperative period and not necessarily a sign of a complication unless prolonged.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

Rationale:

A. "I understand that I need to inspect my feet daily."Daily foot inspection is essential for individuals with diabetes to identify any cuts, blisters, or signs of infection early. Reduced sensation due to peripheral neuropathy can lead to unnoticed injuries that progress to serious complications if untreated.
B. "I will dry my feet thoroughly when I get out of the shower." Keeping the feet dry, especially between the toes, helps prevent fungal infections and skin breakdown. Moist environments encourage fungal growth, which can worsen foot health in diabetic clients.
C. "It is important to apply lotion to my feet and especially my toes to keep my skin in good health." While moisturizing helps prevent dry, cracked skin, lotion should not be applied between the toes. Moisture trapped between the toes increases the risk of fungal infections and skin maceration in diabetic clients.
D. "I will be very careful when I cut my toenails and will be sure to cut them straight across and then file the edges with an emery board." Cutting toenails straight across and filing the edges helps prevent ingrown toenails and reduces the risk of accidental skin injury. Diabetic clients are advised to be cautious during nail care due to impaired healing and infection risk.
E. "I will wear closed toed shoes." Wearing closed-toed shoes protects the feet from injury and trauma. Open-toed shoes or sandals may expose the feet to injury, and diabetic clients may not feel injuries due to neuropathy.
F. "I am glad I can still go barefoot in the house because I never wear shoes at home."Going barefoot, even indoors, increases the risk of stepping on sharp objects and sustaining unnoticed injuries. Clients with diabetes should always wear well-fitting shoes or protective footwear, even at home.
G. "If I have any foot sores or corns come up, I will see my doctor or go to a podiatrist instead of treating it myself." Diabetic clients should avoid self-treating foot problems like sores or corns. Prompt evaluation by a healthcare provider prevents complications like infections or ulcers, which can escalate quickly in this population.

A. Instruct the client to lift no more than 6.8 kg (15 lb) when at home. B. Turn the client by log rolling with a turning sheet. C. Inform the client to shower on the second postoperative day. D. Remove sterile adhesive strips before discharge.

Correct Answer is B

Explanation

Rationale:

A. Instruct the client to lift no more than 6.8 kg (15 lb) when at home: While it is important to avoid heavy lifting after a lumbar laminectomy, specific weight limits should be prescribed by the provider or physical therapist. Also, this instruction is more appropriate for discharge teaching, not immediate postoperative care.

B. Turn the client by log rolling with a turning sheet: Log rolling maintains spinal alignment and minimizes twisting of the spine, which is critical after spinal surgery. It prevents stress on the operative site and reduces the risk of complications such as spinal cord or nerve injury.

C. Inform the client to shower on the second postoperative day: Showering is usually permitted after surgical wounds have started to seal, but the exact timing depends on the surgeon's orders and the condition of the incision. Automatic showering on day two may not be safe for all clients.

D. Remove sterile adhesive strips before discharge: Sterile adhesive strips (such as Steri-Strips) are typically left in place until they fall off naturally or are removed by a healthcare provider at a follow-up visit. Removing them prematurely can increase infection risk or disrupt healing.

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A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is planning care for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

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