The nurse is caring for a patient who returned 4 hours ago from having a lumbar laminectomy. Which change in assessment requires further action?

Indwelling foley catheter has 120 ml clear yellow drainage.

No bowel movement since return from PACU

Neurovascular assessment reveals numbness of bilateral feet.

Pain 7/10 on a 0/10 scale.

Answer and Explanation

The Correct Answer is C

A. Clear yellow drainage from the Foley catheter is a normal finding postoperatively.

B. Not having a bowel movement immediately after surgery is not unusual due to anesthesia and postoperative medications. Bowel function should be monitored.

C. Numbness in both feet could indicate nerve injury, spinal cord compression, or other complications such as hematoma formation, and requires immediate attention.

D. Pain is expected after surgery, but if the pain level is not well-controlled, it should be addressed. A pain score of 7/10 requires further assessment, but it is not as urgent as bilateral numbness.

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Correct Answer is D

Explanation

A. Measuring drainage from the Jackson-Pratt drain is important, but this is not the primary intervention to address post-laminectomy complications.

B. The patient should generally be positioned in a neutral, stable position, but not specifically prone with knees elevated, which may be uncomfortable or inappropriate for the cervical region.

C. Narcotics may be required for pain control, especially postoperatively, so advising the patient to avoid them is inappropriate.

D. Following a cervical spine laminectomy, the nurse should assess the client for any signs of nerve or spinal cord injury, such as difficulty speaking or breathing. These symptoms may indicate spinal cord compression or other complications.

A. Offer Incontinence briefs to be worn while sleeping B. Provide clothing that is easy to put on and take off C. Explain the need to call the nurse using the call bell for help with toileting D. Ask the client if he needs to urinate at least every two hours

Correct Answer is B

Explanation

A. Incontinence briefs are appropriate for overnight use but do not encourage independence in bladder management during the day.

B. Providing easy-to-remove clothing is a practical intervention that enhances the client's independence in managing toileting, especially if they have cognitive impairments. It ensures that the client can quickly respond to the urge to urinate.

C. Explaining the use of a call bell is helpful but may not be the most appropriate approach for a cognitively-impaired client who may forget or struggle with communication.

D. Asking the client every two hours if they need to urinate is helpful but may not be as effective as providing easy access to clothing for quick toileting.

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The nurse is caring for a patient who returned 4 hours ago from having a lumbar laminectomy. Which change in assessment requires further action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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