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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice a reason:
Assessing capillary refill and the color of the extremity is essential for determining the vascular status of the limb. A normal capillary refill time is less than 2 seconds and indicates good blood flow. The color should be consistent with the rest of the body, without pallor or cyanosis, which could indicate compromised circulation.
Choice b reason:
Checking pedal pulses is another critical aspect of assessing vascular integrity. The presence of strong and equal pulses in both feet suggests that the blood supply to the lower extremities is not compromised.
Choice c reason:
While the ACE wrap and Velcro boot are part of the postoperative management to provide support and protection to the affected limb, and hanging weights might be used for traction, these are not part of the physiological assessment of the extremity.
Choice d reason:
Monitoring pin sites for signs of infection, such as redness, swelling, or discharge, is crucial in a client with ORIF. Infection can lead to complications that may affect the healing process and the integrity of the fixation.
Choice e reason:
Evaluating the temperature, sensation, and movement of toes helps in assessing for potential nerve damage or compartment syndrome. Any changes in these parameters should be reported immediately as they may signify serious complications.
Correct Answer is B
Explanation
Choice A Reason
Taking alprazolam with food may help with some gastrointestinal side effects but does not address the client's concerns about dizziness and light-headedness. While it is a practical suggestion, it is not the priority response when the client is experiencing symptoms that could affect their safety¹.
Choice B Reason
The priority for the nurse is to ensure the client's safety. Dizziness and light-headedness can increase the risk of falls or accidents, especially when performing tasks that require alertness, such as driving or operating machinery. Therefore, advising the client to avoid dangerous activities is the most immediate and appropriate response¹.
Choice C Reason
While it is true that alprazolam is often prescribed for short-term use and some side effects may diminish over time, this does not provide the client with a solution to their current symptoms. The nurse should address the client's immediate concerns and ensure their safety before discussing the duration of medication use¹.
Choice D Reason
Using sugarless gum or candy can help with dry mouth, which is a common side effect of alprazolam. However, this advice does not address the more serious side effects of dizziness and light-headedness that the client is experiencing. Therefore, it is not the priority response but can be included as additional advice¹.
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