The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications?

Progress diet slowly from ice chips to clear liquids.

Maintain intervascular infusion rate.

Apply intermittent pneumatic compression devices.

Obtain frequent pain level assessments.

Answer and Explanation

The Correct Answer is C

A.   Progressing the diet is important but does not address immobility-related complications.
B.   Maintaining the IV infusion rate is necessary but not specific to preventing complications from immobility.
C.   Applying intermittent pneumatic compression devices helps prevent deep vein thrombosis (DVT), a significant risk for immobile clients post-surgery. This is a critical preventative measure for immobility-related complications.
D.   Frequent pain assessments are important but do not specifically prevent complications from immobility.

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Correct Answer is ["A","D","E","F","H"]

Explanation

A. Oxygen saturation of 98% on room air indicates that the client is maintaining adequate oxygenation without the need for supplemental oxygen.
B. A urine output of 20 ml within the last one hour is insufficient and could indicate an acute kidney injury.
C. Presence of crackles indicates ongoing pulmonary involvement, which does not suggest stabilization.
D. A heart rate within the normal range for a 7-year-old child (70-120 beats/minute), showing improvement from the previously irregular and elevated rate.
E. Respiratory rate of 26 breaths/minute is now within the normal range for a child (20-30 breaths/minute), indicating improved respiratory function.
F. A blood pressure of 126/76 mm Hg is within the normal range for a child.

G. Tall T wave and widened QRS complex suggest hyperkalemia, which is a serious condition and does not indicate stabilization.
H. An oral temperature of 37.1 C Indicates that the fever has resolved, suggesting that the infection or inflammatory response is under control.

A. Begin with questions that are less sensitive in nature. B. Share personal values to put the client at ease. C. Get the most difficult questions over with first. D. Ask questions in a vague, non-specific format.

Correct Answer is A

Explanation

A.Beginning with less sensitive questions helps establish trust and rapport with the client, making it easier to discuss more difficult topics later. This approach can make the client feel more comfortable and less threatened, thereby improving the quality of the information gathered.

B.Sharing personal values can introduce bias and potentially influence the client's responses, making the interview less objective.

C.Starting with the most difficult questions can make the client feel anxious and defensive, reducing the likelihood of obtaining honest and thorough responses.

D.Asking vague, non-specific questions can lead to ambiguous answers and fail to provide the detailed information needed for a proper assessment.

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The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications?

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Which assessment findings indicate that the client has stabilized? Select all that apply.

Correct Answer is ["A","D","E","F","H"]

Explanation

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Correct Answer is A

Explanation

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