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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Free Nursing Study Resources

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

Explanation

Rationale:
A. Ferrous sulfate: Ferrous sulfate is an iron supplement and does not directly interact with warfarin's anticoagulant effect. While some mild interactions are possible, it is not generally contraindicated unless specifically advised due to individual clinical conditions.

B. Aspirin: Aspirin has antiplatelet effects and can increase the risk of bleeding when taken with warfarin. The combination enhances anticoagulation and significantly raises the chance of gastrointestinal or systemic bleeding.

C. Naproxen: Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can interfere with platelet function and irritate the gastrointestinal lining, increasing the risk of bleeding when combined with warfarin.

D. Echinacea: Echinacea may interfere with liver enzyme activity and affect the metabolism of warfarin, potentially altering its effectiveness. Herbal supplements can cause unpredictable interactions and should generally be avoided while on warfarin.

E. Dextromethorphan: Dextromethorphan is a common cough suppressant and does not have significant interactions with warfarin. It is generally considered safe for occasional use in clients taking anticoagulants.

A. Report of itching B. Distended jugular veins C. Report of low back pain D. Temperature 37.8° C (100° F)

Correct Answer is A

Explanation

Rationale:
A. Report of itching: Itching is a common early sign of an allergic transfusion reaction. These reactions occur due to sensitivity to plasma proteins in the donor blood and may also present with hives, flushing, or mild respiratory symptoms.

B. Distended jugular veins: Jugular vein distention is a sign of fluid overload or circulatory compromise, such as transfusion-associated circulatory overload (TACO), not an allergic reaction.

C. Report of low back pain: Low back pain is more indicative of an acute hemolytic reaction, which results from ABO incompatibility. This is a serious and life-threatening reaction distinct from allergic responses.

D. Temperature 37.8° C (100° F): A mild elevation in temperature may be seen with febrile non-hemolytic transfusion reactions, which are different from allergic reactions. Allergic reactions usually involve skin and respiratory symptoms.

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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?

Nursing Test Bank

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Explanation

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