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 C
Explanation
Choice A reason: This choice is incorrect. Painless, raised purple nodules on the hard palate are not typically indicative of squamous cell carcinoma.
Choice B reason: This choice is incorrect. A small macule with a yellow-brown scale does not describe squamous cell carcinoma, which often presents as a firm nodule with a scaly crust.
Choice C reason: This is the correct choice. Squamous cell carcinoma can present as a firm nodule with a hard, scaly crust on the skin.
Choice D reason: Yellow white patches of growth on the tongue are more indicative of conditions such as oral leukoplakia, not squamous cell carcinoma.
Correct Answer is B
Explanation
Choice A reason: Avoiding driving in winter is not necessary unless it is a personal trigger for Raynaud's attacks. It's more important to keep warm and manage stress.
Choice B reason: Stress management classes can teach techniques to control stress, which is beneficial for clients with Raynaud's disease as stress can trigger episodes.
Choice C reason: Using nicotine gum to quit smoking is a positive step for overall health, but it is not directly related to the management of Raynaud's disease.
Choice D reason: Limiting coffee intake may help some individuals with Raynaud's disease, as caffeine can constrict blood vessels, but it is not a universal recommendation.
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