A nurse is planning care for a client who has just had spinal surgery. Which of the following actions should the nurse include in the plan of care?
Perform neurological checks every 2 hours.
Position the patient in a chair every 2 hours.
Inspect clear drainage on the spinal dressing.
Continue criminal checks.
The Correct Answer is A
Choice A reason: Neurological checks are essential after spinal surgery to monitor for any changes or deterioration in the patient's neurological status. The frequency of these checks can vary based on the patient's condition, but a common standard is to perform them every 4 hours or sooner. However, in some cases, especially immediately post operation, checks may be required more frequently, such as every 2 hours, to ensure any complications are identified and managed promptly.
Choice B reason: While mobilization is an important aspect of postsurgical care to prevent complications such as deep vein thrombosis, positioning a patient in a chair every 2 hours may not be appropriate immediately following spinal surgery. The patient's mobility and pain level must be assessed, and activities should be gradually increased as tolerated.
Choice C reason: Inspecting the spinal dressing is important to identify signs of infection or complications. However, clear drainage is not typically expected and could indicate cerebrospinal fluid leakage, which requires immediate medical attention.
Choice D reason: The term "criminal checks" is not relevant to nursing care and seems to be a typographical error. The nurse's focus should be on clinical assessments and interventions related to the patient's health status.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This choice is incorrect because an oral cholangiogram does not involve putting a camera down the throat. That procedure is more akin to an endoscopy.
Choice B reason: This statement is correct. An oral cholangiogram involves taking an Xray examination of the gallbladder after the patient has taken an iodine based contrast agent orally. The procedure is used to diagnose problems related to the gallbladder, such as gallstones or issues with bile flow.
Choice C reason: This choice is incorrect because an oral cholangiogram does not involve putting medication into the gallbladder to dissolve stones. That description is more consistent with nonsurgical treatments for gallstones, such as oral bile acid pills.
Choice D reason: This choice is incorrect as it describes a different procedure known as extracorporeal shock wave lithotripsy (ESWL), which uses shock waves to break up gallstones.
Correct Answer is B
Explanation
Choice A reason: Pain is a common postoperative symptom and should be managed appropriately. However, it is not typically considered a priority over other complications that can have more immediate and severe consequences.
Choice B reason: Hemorrhage is a significant risk after TURP and can be life-threatening. It is considered a priority because active bleeding can lead to shock and requires immediate intervention.
Choice C reason: Infection is a potential complication after any surgery, including TURP. While important to monitor for, it is generally not as immediately life-threatening as hemorrhage.
Choice D reason: Urinary retention can occur after TURP, but it is often anticipated and managed with the placement of a urinary catheter. It is a concern but not the highest priority immediately following surgery.
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