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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Stridor is a high-pitched sound heard with breathing and is not related to the pattern described.
Choice B reason: Kussmaul respirations are deep and labored, typically associated with metabolic acidosis, not the pattern described.
Choice C reason: Apneustic respirations are characterized by prolonged inspiratory phases, which is not the pattern described.
Choice D reason: This is the correct choice. Cheyne Stokes respirations are characterized by a cyclic pattern of increasing and decreasing tidal volumes followed by periods of apnea, fitting the description provided.
Correct Answer is A
Explanation
Choice A reason: A blood pressure reading of 124/79 mm Hg is considered elevated. The normal range for blood pressure is less than 120/80 mm Hg. Elevated blood pressure is when readings consistently range from 120129 systolic and less than 80 mm Hg diastolic.
Choice B reason: Stage 1 hypertension is defined by a systolic blood pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg. The client's blood pressure does not fall into this category.
Choice C reason: Stage 2 hypertension is characterized by a systolic blood pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher. The client's blood pressure is below these levels.
Choice D reason: A normal blood pressure reading is typically below 120/80 mm Hg. Although the client's diastolic pressure is within the normal range, the systolic pressure is above normal, thus it does not qualify as a normal blood pressure reading.
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