A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take?
Log roll the client every 2 hr.
Expect clear drainage on the spinal dressing.
Assist the client to sit upright in a chair for 4 hr at a time.
Elevate the client's legs when he is sitting in a chair.
The Correct Answer is A
A. This technique helps to prevent pressure ulcers and assists in maintaining proper spinal alignment, which is essential after such a surgery.
B. Clear drainage on the spinal dressing is not typically expected and could indicate an infection or other complication.
C. Assisting the client to sit upright in a chair for extended periods is not standard practices immediately following spinal fusion, as these actions may put undue stress on the spine during the critical initial healing phase.
D. Elevating the client's legs while sitting are not standard practices immediately following spinal fusion, as these actions may put undue stress on the spine during the critical initial healing phase
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Related Questions
Correct Answer is B
Explanation
B. If the patient expresses confusion or uncertainty about the surgical procedure, the nurse should notify the surgeon or appropriate healthcare provider promptly. The surgeon may need to revisit the discussion with the patient, clarify any misunderstandings, and answer any questions to ensure informed consent.
A. This option involves the nurse providing the patient with a comprehensive explanation of the planned surgical procedure, including the purpose, risks, benefits, and alternatives. That however, is the role of the provider.
C. While the operating room nurse may have knowledge about the planned surgical procedure, it is ultimately the responsibility of the surgeon or healthcare provider performing the procedure to ensure that the patient understands and consents to the surgery.
D. Administering preoperative antibiotics and managing sedative medications are important aspects of preoperative care but are not directly related to addressing the patient's concerns about understanding the planned surgical procedure.
Correct Answer is ["A","D"]
Explanation
A. The heart rate has increased from 92/min on Day 1 to 108/min on Day 2. This significant increase warrants immediate follow-up as it may indicate pain, anxiety, or an underlying physiological issue such as hemorrhage, infection, or cardiac complications.
D. The temperature has increased from 36.4°C (97.5°F) on Day 1 to 37.2°C (98.9°F) on Day 2. While this increase is within a relatively normal range, it is approaching a fever range (> 38°C or 100.4°F) and warrants further evaluation to determine if there is an underlying infection or inflammation.
B. The oxygen saturation remains relatively stable, from 95% on Day 1 to 96% on Day 2. While it is important to monitor oxygen saturation, the minimal change does not indicate an immediate concern. However, it should still be monitored closely for any further decrease.
C. Edema is not directly mentioned in the provided data. While edema can be indicative of various health issues, there is no evidence in the given information to suggest its presence or severity as a concern requiring immediate follow-up.
E. Urine color is not provided in the given data. While changes in urine color can indicate dehydration or other health issues, it is not mentioned in the assessment findings and therefore not a factor for immediate follow-up based on the information provided.
F Pedal pulses were noted as +2 on Day 1, indicating that they were present and normal. Unless there is a significant change in pedal pulses or signs of vascular compromise, such as decreased or absent pulses, there is no immediate need for follow-up based on the given information.
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