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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason: Physical therapy may be prescribed postoperatively to aid in recovery, but it does not directly interfere with the function of a pacemaker.

Choice B reason: Checking serum cardiac enzyme levels is a common practice after heart surgery to assess for any damage to the heart muscle, which would not typically require clarification in the context of pacemaker insertion.

Choice C reason: An MRI of the chest should be clarified with the healthcare provider because MRI can interfere with pacemaker function. Patients with pacemakers are generally advised to avoid MRI unless the pacemaker is Incompatible, due to the risk of the magnetic field affecting the device's operation.

Choice D reason: A low sodium diet may be recommended for patients with heart conditions to manage blood pressure and fluid retention, but it is not directly related to the care of a pacemaker.

A. Bradycardia B. An increase in platelets C. An increase in RBCs D. Localized edema E. An increase in neutrophils

Correct Answer is ["D","E"]

Explanation

Choice A reason: Bradycardia, or a slower than normal heart rate, is not typically an indication of infection. It can be related to other health issues or medication effects.

Choice B reason: An increase in platelets, or thrombocytosis, can occur in response to various conditions, but it is not a specific indicator of infection in diabetic foot pain.

Choice C reason: An increase in RBCs, or erythrocytosis, is generally not associated with infection. It could indicate other conditions such as polycythemia vera.

Choice D reason: Localized edema, or swelling, can be a sign of infection, especially if accompanied by other symptoms such as redness, warmth, and pain.

Choice E reason: An increase in neutrophils, a type of white blood cell, often indicates the body's response to an infection. Neutrophils are part of the immune system's first line of defense against pathogens.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who recently had surgery for the insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

Correct Answer is C

Explanation

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

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