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. Metabolic alkalosis would be indicated by an elevated pH and HCO3, but the PaCO2 would typically be higher due to compensatory hypoventilation.
Choice B reason: This is the correct choice. The elevated pH and low PaCO2 indicate respiratory alkalosis, likely due to hyperventilation. The normal HCO3 suggests that there has been no renal compensation, hence 'uncompensated'.
Choice C reason: This choice is incorrect because, for metabolic alkalosis to be uncompensated, the PaCO2 would typically be normal or high, not low.
Choice D reason: This choice is incorrect. Respiratory acidosis would be indicated by a low pH and high PaCO2, which is not the case here.
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.
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