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 B
Explanation
Choice A rationale
The vital signs presented in this choice are within the normal range. A blood pressure of 118/76 mm Hg is considered normal. A heart rate of 92/min is slightly elevated but still within the normal range (60-100 beats per minute). A temperature of 38.1° C (100.6° F) indicates a slight fever, which could be a response to an infection or inflammation. An oxygen saturation of 95% on room air is within the normal range (95%-100%).
Choice B rationale
The vital signs presented in this choice indicate that the patient may be experiencing a respiratory issue. A blood pressure of 126/84 mm Hg is slightly elevated but still within the acceptable range. A heart rate of 104/min is high, indicating that the heart is working harder than normal. A respiratory rate of 24/min is also high, suggesting that the patient may be having difficulty breathing. A temperature of 38.5 C (101.3* F) indicates a fever, which could be a response to an infection. An oxygen saturation of 92% on room air is below the normal range (95%-100%), suggesting that the patient is not getting enough oxygen. This is the vital sign that should be addressed first.
Correct Answer is B
Explanation
Choice A rationale
Holding tube feeding 1 hour before and 2 hours after to avoid clumping is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice B rationale
Monitoring the patient for lethargy and drowsiness is important as these may indicate a high drug level of Dilantin (phenytoin), which can lead to toxicity.
Choice C rationale
Informing the patient that they may experience increased and large amounts of urinary output is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice D rationale
Advising the patient to use an extra soft toothbrush to avoid gum bleeding is a general recommendation for patients on anticoagulant therapy, not specifically for those taking Dilantin (phenytoin)1011.
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