A patient returns to the unit after having surgery with spinal anesthesia. What does the nurse know is/are the best action(s) to take to decrease the possibility of spinal headache? Select All That Apply
Administer morphine 1-2 mg IV
Ambulate the client as soon as she gets feelings back
Increase fluid intake
Encourage the patient to stay flat in bed
Position the client in high fowlers position
Correct Answer : C,D
A. Administer morphine 1-2 mg IV
Administering morphine is not a preventive measure for spinal headaches. It may be considered for pain relief if the patient experiences discomfort after the effects of spinal anesthesia wear off.
B. Ambulate the client as soon as she gets feelings back
Ambulating the patient too soon after spinal anesthesia is generally not recommended. Staying in bed initially helps prevent complications like spinal headaches.
C. Increase fluid intake
Adequate hydration is important after spinal anesthesia to help maintain cerebrospinal fluid volume. Increasing fluid intake can reduce the risk of developing a spinal headache.
D. Encourage the patient to stay flat in bed
Remaining in a flat or slightly elevated position helps minimize cerebrospinal fluid leakage from the puncture site, reducing the likelihood of developing a spinal headache. This position is typically recommended for a specific duration after spinal anesthesia.
E. Position the client in high Fowler's position
Placing the patient in high Fowler's position (sitting upright) may increase the risk of cerebrospinal fluid leakage, potentially leading to a spinal headache. This position is not recommended for preventing spinal headaches after spinal anesthesia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decreased ascites
Ascites (accumulation of fluid in the abdominal cavity) is more directly related to portal hypertension and liver cirrhosis. While lactulose may contribute to fluid balance, its primary therapeutic effect in hepatic encephalopathy is the reduction of ammonia levels.
B. Decreased ammonia level
Lactulose is a medication commonly used in the treatment of hepatic encephalopathy, a condition associated with liver disease. The therapeutic effect of lactulose in this context is to reduce blood ammonia levels. Lactulose works by promoting the excretion of ammonia in the form of ammonium ions in the colon, thereby lowering ammonia concentrations in the blood.
C. Decreased jaundice
Jaundice is often associated with liver dysfunction, but lactulose is not primarily used to address jaundice. Its primary role in liver disease is in the management of hepatic encephalopathy.
D. Decreased blood pressure
Blood pressure is not a direct therapeutic target of lactulose in the context of liver disease. Lactulose's primary therapeutic effect is related to reducing ammonia levels and managing hepatic encephalopathy.
Correct Answer is ["75"]
Explanation
To calculate the rate of IV infusion, the nurse should divide the volume of fluid by the time in hours.
In this case, 750 mL divided by 10 hours equals 75 mL per hour.
Therefore, the nurse should program the IV infusion pump for 75 mL per hour.
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