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?

Instruct the client to lift no more than 6.8 kg (15 lb) when at home.

Turn the client by log rolling with a turning sheet.

Inform the client to shower on the second postoperative day.

Remove sterile adhesive strips before discharge.

Answer and Explanation

The Correct Answer is B

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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Correct Answer is D

Explanation

Rationale:
A. A client who is newly diagnosed with type 1 diabetes mellitus and cannot afford insulin: This situation requires case management or social work referral to assist with access to medications and insurance. It does not indicate the need for palliative care, as diabetes is a chronic condition that can be managed effectively with proper support.

B. A client who has Meniere’s disease and cannot safely ambulate due to vertigo: While vertigo significantly affects quality of life, it is not life-limiting. This client would benefit more from physical therapy, home safety evaluation, and symptom management, rather than palliative care services.

C. A client who had a stroke and cannot eat or drink without choking: This client may need speech therapy, nutritional support, or possibly enteral feeding, but not necessarily palliative care unless their overall prognosis is poor or complications are expected to worsen.

D. A client whose medications to manage Parkinson’s disease are no longer effective: Palliative care is appropriate for clients with progressive, life-limiting illnesses like advanced Parkinson’s disease, especially when symptoms can no longer be adequately controlled with standard treatments. It focuses on comfort, quality of life, and support for complex symptom management.

A. "If I can keep my HbA1c less than 6.5% (less than 7%), I will be cured of diabetes." B. "I will check my blood sugar level before exercising." C. "I should have my eyes checked every 2 years." D. "I should soak my feet daily in warm, soapy water."

Correct Answer is B

Explanation

Rationale:
A. "If I can keep my HbA1c less than 6.5% (less than 7%), I will be cured of diabetes.": Maintaining an HbA1c below 7% is important for managing type 1 diabetes and reducing complications, but it does not eliminate the disease. Type 1 diabetes is a lifelong condition due to permanent loss of insulin production.

B. "I will check my blood sugar level before exercising.": Blood glucose monitoring before physical activity is essential to prevent hypoglycemia. Exercise lowers blood sugar levels, and clients with type 1 diabetes must assess their levels beforehand to determine if carbohydrate intake or insulin adjustment is needed.

C. "I should have my eyes checked every 2 years.": Clients with type 1 diabetes should have a comprehensive dilated eye exam annually, not every two years, to monitor for diabetic retinopathy, a common microvascular complication.

D. "I should soak my feet daily in warm, soapy water.": Soaking the feet is not recommended because it can lead to skin maceration and increase the risk of infection. Gentle washing and thorough drying—especially between the toes—are safer practices for foot care.

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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?

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