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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Serum IgA levels are not typically associated with acute pancreatitis. IgA is an antibody that plays a crucial role in the immune function of mucous membranes. Changes in serum IgA levels can occur in various conditions, but they are not a characteristic finding in acute pancreatitis.
Choice B rationale
Decreased serum bilirubin is not commonly associated with acute pancreatitis. While jaundice (indicated by increased bilirubin levels) can occur in some cases of acute pancreatitis due to blockage of the bile duct, decreased bilirubin levels are not a typical finding.
Choice C rationale
Elevated serum albumin is not typically associated with acute pancreatitis. In fact, levels of albumin, a protein made by the liver, can sometimes decrease in acute pancreatitis due to inflammation and leakage of protein into the abdomen.
Choice D rationale
Elevated serum amylase is commonly associated with acute pancreatitis. Amylase is an enzyme that helps digest carbohydrates. It’s produced in the pancreas and the glands that make saliva. When the pancreas is inflamed, levels of amylase in the blood often rise.
Correct Answer is B
Explanation
Choice A rationale
While it’s true that electrical burns can cause more skin damage than what can be seen on the skin, this statement does not fully address the client’s misconception about the severity of their burn.
Choice B rationale
This is the best response because it directly addresses the client’s misconception and provides accurate information. Electrical burns can indeed have small amounts of skin damage but cause more extensive damage beneath the skin. This is because the electrical current can pass through the body and damage internal tissues and organs, even if the visible wound on the skin is small.
Choice C rationale
While electrical burns can cause reddened or purplish skin, they do not typically cause blistering. Furthermore, this statement does not address the client’s misconception about the severity of their burn.
Choice D rationale
This statement is incorrect. Electrical burns are not typically minor. They can cause serious internal injuries and complications, even if the visible wound on the skin is small.
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