A nurse is caring for a client who has arrived in the postoperative unit following a laminectomy and spinal fusion. Which action should the nurse take?

Assist the client to turn, having them grasp the side rails.

Maintain strict bedrest for 48 hours postoperatively.

Assess the client's pain level and administer pain medication as needed.

Place the client in the prone position.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Assisting the client to turn by having them grasp the side rails is not recommended immediately following a laminectomy and spinal fusion. This action could place undue stress on the surgical site and potentially disrupt the healing process. Postoperative care typically involves minimizing movement of the spine to prevent complications.

Choice B reason:

Maintaining strict bedrest for 48 hours postoperatively is not a current standard of care following a laminectomy and spinal fusion. Early ambulation, as tolerated, is encouraged to promote circulation and prevent complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE).

Choice C reason:

Assessing the client's pain level and administering pain medication as needed is a critical nursing intervention postoperatively. Effective pain management is essential for promoting patient comfort, facilitating early mobilization, and preventing complications. Pain assessment and management should be tailored to the individual's needs and carried out with regular monitoring.

Choice D reason:

Placing the client in the prone position is not typically advised following a laminectomy and spinal fusion, as it may put pressure on the surgical site and cause discomfort. The preferred position is usually on the back or occasionally on the side with proper support, depending on the surgeon's protocol and the client's comfort.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A Reason
Limit setting may be helpful for a client who displays hypervigilance and refuses to attend unit activities, as it can provide clear expectations and help reduce anxiety. However, this behavior does not pose an immediate risk to the safety of others, making limit setting less essential compared to behaviors that could lead to harm.

Choice B Reason
While being flirtatious toward staff members may be inappropriate and require intervention, it is typically addressed through professional boundaries rather than limit setting. Limit setting in this context would involve clarifying acceptable behaviors within the therapeutic relationship.

Choice C Reason
Urging another client to commit violence is a behavior that necessitates immediate limit setting. This behavior poses a direct threat to the safety of others and disrupts the therapeutic environment. Limit setting here would involve immediate intervention to prevent harm and to maintain a safe environment for all clients.

Choice D Reason
A client who clings to the nurse and seeks advice on inconsequential matters may benefit from limit setting to encourage independence and appropriate use of staff time. However, this behavior is not as disruptive or dangerous as inciting violence, making it a lower priority for limit setting.

A. Give the ordered dose of dantrolene. B. Call the physician for an order for metoprolol. C. Increase the rate of lactated Ringer's. D. Ask the physician to order liver function tests.

Correct Answer is A

Explanation

Choice A Reason:
Dantrolene is used in the management of malignant hyperthermia, a life-threatening complication characterized by muscle rigidity and elevated temperature, often triggered by certain anesthetics. The patient's symptoms of muscle rigidity and brown urine, which may indicate myoglobinuria, along with elevated temperature and heart rate, are suggestive of this condition. Dantrolene acts by reducing calcium release from the sarcoplasmic reticulum of skeletal muscle, thereby reducing muscle contraction and metabolic demand.

Choice B Reason:
Metoprolol, a beta-blocker, is not the first-line treatment for symptoms suggestive of malignant hyperthermia. While it can reduce heart rate and blood pressure, it does not address the underlying pathophysiology of malignant hyperthermia and is not indicated in this scenario.

Choice C Reason:
Increasing the rate of lactated Ringer's solution is not the primary intervention for malignant hyperthermia. While maintaining hydration is important, it does not directly counteract the pathophysiological processes at play in malignant hyperthermia.

Choice D Reason:
While liver function tests can be important in assessing overall organ function post-operatively, they are not the immediate priority in a suspected case of malignant hyperthermia. The priority is to treat the acute and life-threatening symptoms first.

View Question and Answer

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

A nurse is caring for a client who has arrived in the postoperative unit following a laminectomy and spinal fusion. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For which of the following behaviors would limit setting be most essential? The client:

Correct Answer is C

Explanation

The nurse is assessing a post-operative client and notices that the client's urine is brown and they are experiencing muscle rigidity. The vital signs are T: 102.5 F; HR: 112; RR: 20 and BP 124/84. What is the most appropriate nursing action?

Correct Answer is A

Explanation

The physician prescribes risperidone for a client with schizophrenia who displays delusions, hallucinations, apathy, and social isolation. Which symptoms should be monitored to evaluate improvement?

The nurse has administered warfarin 2.5 mg orally daily for three days to a client who has deep vein thrombosis. The client's International Normalized Ratio (INR) today is 5.0. The nurse notifies the healthcare provider because today's dose of the medication should be:

When teaching a client about cystitis, the nurse explains that women are more prone to the infection than men. Which of the following best explains a woman's increased susceptibility?

The nurse is teaching a client about preventing osteoporosis. Which statement made by the client indicates a need for further teaching? "I will:

What instruction for oral administration of methotrexate should the nurse include when teaching a client diagnosed with rheumatoid arthritis?

The nurse is sitting with a client diagnosed with schizophrenia, who starts to laugh uncontrollably, although the nurse has not said anything funny. The nurse should say:

The nurse would assess for which clinical manifestations in a client suspected of having diabetic ketoacidosis? (Select all that apply)