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 ["B","D","E"]

Explanation

A. Danging the leg is not advisable as it may increase swelling. Elevation is more beneficial for reducing swelling.

B. An ACE bandage helps stabilize the ankle and reduce swelling.

C. The client should stay off the ankle for several days, but it’s important to resume gentle movement and weight-bearing once swelling and pain allow to promote healing and prevent stiffness.

D. Compression also reduces swelling and provides support to the injured area.

E. Applying a cold pack reduces inflammation and pain during the acute phase of a sprain.

A. "Avoid foods high in fiber." B. "Be sure to plenty of fluids in your diet." C. Take your prescribed stool softener with your morning medications." D. "Limit activity because you will be dizzy from the medication" E. "Take the opioid with a full 8 ounce glass of water and be sure to sit upright for at least 30 minutes after."

Correct Answer is ["B","C","E"]

Explanation

A. A diet high in fiber is important to prevent constipation, a common side effect of opioid use.

B. Adequate fluid intake helps to prevent dehydration and constipation.

C. Taking a stool softener daily can help mitigate the constipating effects of opioids.

D. While dizziness can occur, clients should be encouraged to maintain an appropriate level of activity with precautions.

E. Taking the opioid with a full glass of water and sitting upright can help prevent esophageal irritation and ensure proper swallowing of the medication.

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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

The patient has been admitted to the med-surg unit with the diagnosis of sprained ankle. Which of the following interventions are important to implement for this patient? (SELECT ALL THAT APPLY).

Correct Answer is ["B","D","E"]

Explanation

Which of the following teaching instructions should be included for the patient with newly prescribed opioid analgesic for pain? (SELECT ALL THAT APPLY).

Correct Answer is ["B","C","E"]

Explanation

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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?

Your neighbor returns home from the Emergency Department following treatment for a right ankle sprain and asks you, a nurse, to explain what will happen now that he is home. You recognize that continuing short term treatment will most likely include: (SELECT ALL THAT APPLY)

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