Which action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)?
Check ability to plantar and dorsiflex the foot.
Log roll the patient from side to side every 2 hours.
Ask about pain management with the patient-controlled analgesia (PCA).
Determine the patient's readiness to ambulate.
The Correct Answer is B
Choice A rationale
Checking plantar and dorsiflexion assesses neurological status requiring nursing expertise and cannot be delegated to UAP.
Choice B rationale
Log rolling every 2 hours maintains spinal alignment post-laminectomy, a straightforward, standardized task suitable for experienced UAP.
Choice C rationale
PCA assessment involves evaluating pain control methods, which require critical nursing judgments and is not appropriate to delegate.
Choice D rationale
Determining readiness to ambulate involves comprehensive assessment skills, evaluating multiple factors like pain, strength, and hemodynamic stability, beyond UAP’s scope of practice. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Glucagon IM is inappropriate for a glucose of 85 mg/dL, which is within normal preprandial ranges of 70-100 mg/dL. It is reserved for severe hypoglycemia with symptoms like unconsciousness.
Choice B rationale
Calling the MD is unnecessary when blood glucose is in the normal range and the patient is symptomatic. Nutritional intake is the next logical step in management.
Choice C rationale
Holding insulin and allowing the patient to eat is appropriate for 85 mg/dL. Nutritional intake stabilizes glucose levels, maintaining euglycemia without risking hypoglycemia from insulin.
Choice D rationale
Administering 10 units of Humalog risks causing hypoglycemia, as this dose is excessive for a glucose level of 85 mg/dL. Insulin use is not indicated here.
Choice E rationale
Administering dextrose IVP unnecessarily increases glucose levels. It is inappropriate unless the patient is symptomatic and glucose levels drop below 70 mg/dL.
Choice F rationale
Administering 7 units of Humalog risks hypoglycemia for a glucose level of 85 mg/dL, as the dose is excessive and unnecessary without elevated glucose.
Choice G rationale
Administering 5 units of Humalog poses a risk for hypoglycemia and is not indicated with normal glucose levels. Nutritional intake alone suffices.
Choice H rationale
Administering 15 units of Humalog is inappropriate and dangerous for a normal glucose level, as it likely induces hypoglycemia. Insulin use should be avoided here. .
Correct Answer is B
Explanation
Choice A rationale
Moving the legs independently before turning can strain the spine and disrupt the surgical site. It does not ensure spinal alignment, which is critical after a laminectomy and discectomy to promote healing and prevent complications.
Choice B rationale
Placing a pillow between the legs and turning the body as a unit maintains spinal alignment, reducing stress on the surgical site. This technique, known as logrolling, ensures the spine remains stable during movement.
Choice C rationale
Turning the head and shoulders first, followed by the hips, legs, and feet, can result in twisting of the spine, which could compromise the surgical site and delay healing. It is not recommended.
Choice D rationale
Using side rails for movement requires significant upper body strength and may cause twisting of the spine, which is contraindicated post-spinal surgery. This method poses a risk of disrupting the surgical repair.
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