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 ["A","B","C","G"]
Explanation
Choice A rationale
Contact with infected blood or bodily fluids is a major risk factor for Hepatitis B. The virus is present in the blood and bodily fluids of infected individuals and can be transmitted through direct contact.
Choice B rationale
Unprotected sex is a significant risk factor for Hepatitis B. The virus can be transmitted through sexual contact with an infected person.
Choice C rationale
Sharing dirty needles is a well-known risk factor for Hepatitis B. This is particularly a concern among individuals who inject drugs.
Choice D rationale
Sharing eating utensils is not typically a risk factor for Hepatitis B. The virus is not usually transmitted through casual contact or sharing of utensils.
Choice E rationale
Contact with contaminated food or water is not a risk factor for Hepatitis B. The virus is not transmitted through food or water.
Choice F rationale
Exposure to chemicals or toxins is not a risk factor for Hepatitis B. While certain chemicals and toxins can damage the liver, they do not directly cause Hepatitis B3.
Choice G rationale
Contact with infected feces is not typically a risk factor for Hepatitis B. The virus is primarily transmitted through blood and bodily fluids, not fecal matter.
Choice H rationale
Heavy alcohol consumption is not a direct risk factor for Hepatitis B. However, it can contribute to liver damage and complicate the course of the disease if a person is infected.
Correct Answer is A
Explanation
Choice A rationale
A patient with type 1 diabetes who has taken a high dose of insulin is at the highest risk for developing hypoglycemia. Insulin lowers blood glucose levels, and taking a high dose can cause the levels to drop too low.
Choice B rationale
A patient with type 2 diabetes who has not taken any medication is not at a high risk for developing hypoglycemia. Without medication, their blood glucose levels may be high, not low.
Choice C rationale
An elderly patient who is taking an antibiotic for an infection is not at a high risk for developing hypoglycemia. Antibiotics do not typically affect blood glucose levels.
Choice D rationale
A patient with metabolic syndrome who is taking a statin to lower cholesterol levels is not at a high risk for developing hypoglycemia. Statins do not typically affect blood glucose levels.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.