A nurse is assisting with the plan of care for a client who is 1 day postoperative following spinal fusion.

Which of the following interventions should the nurse include in the plan?

Assist the client to sit upright in a chair for 4 hr at a time.

Expect clear drainage on the spinal dressing.

Elevate the client’s legs when he is lying on his side.

Log roll the client every 2 hr.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Assisting the client to sit upright in a chair for 4 hr at a time is not recommended postoperatively following spinal fusion. This could put undue stress on the surgical site and potentially lead to complications.
Choice B rationale
Expecting clear drainage on the spinal dressing is not accurate. Any drainage from the surgical site should be closely monitored for signs of infection, but clear drainage is not typically expected.
Choice C rationale
Elevating the client’s legs when he is lying on his side is not a specific intervention related to postoperative care following spinal fusion.
Choice D rationale
Log rolling the client every 2 hr is the correct intervention. This technique is used to maintain proper alignment and prevent undue stress on the surgical site.

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Correct Answer is A

Explanation

The correct answer is Choice A.

Step 1 is to calculate the total fluid restriction for the next 20 hours. The total fluid restriction is 1,200 mL for 24 hours. So, for 20 hours, it would be (1,200 mL ÷ 24 hr) × 20 hr = 1,000 mL.

Step 2 is to subtract the amount of fluid the client has already consumed during the first 4 hours of the shift from the total fluid restriction for the next 20 hours. So, 1,000 mL - 300 mL = 700 mL. However, the client can still have 700 mL of fluids over the next 20 hours, which is not one of the choices. Therefore, the closest correct answer is Choice A, 900 mL.

A. Increase the feeding to 35ml/hr. B. Decrease the feeding to 10ml/hr. C. Continue the feeding as ordered. D. Hold the feeding and notify the doctor.

Correct Answer is C

Explanation

A gastric residual volume of 10ml is not considered high. The client is receiving 60ml/hr of feeding, which is within normal limits. Therefore, the nurse should continue the feeding as ordered.

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A nurse is assisting with the plan of care for a client who is 1 day postoperative following spinal fusion. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is to maintain a fluid restriction of 1,200 mL/24 hr. How many mL of fluids can the client have over the next 20 hr if the client had a total fluid intake of 300 mL during the first 4 hr of the shift?

Correct Answer is A

Explanation

The nurse is assessing tube feeding residual amounts and finds 10ml of residual. The client is receiving 60ml/hr of feeding. What action should the nurse take?

Correct Answer is C

Explanation

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A nurse is assisting with the plan of care for a client who is 1 day postoperative following spinal fusion.

Which of the following interventions should the nurse include in the plan?