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 C
Explanation
C. This information is important to communicate to the surgical and anesthesia team as it indicates a potential family history of adverse reactions to anesthesia. Family history of anesthesia-related complications, especially in close relatives, can influence the anesthetic plan and help mitigate potential risks during surgery.
A. Clear fluids, such as apple juice, are typically allowed up to 2 hours before surgery, but the specific fasting instructions may vary depending on the institution's protocol and the type of surgery planned.
B. This information provides insight into the patient's caffeine consumption habits but it is not typically considered a critical factor to communicate to the surgical and anesthesia team before surgery.
D. Knowing the duration of aspirin cessation allows the anesthesia team to assess the patient's coagulation status and adjust the perioperative management accordingly. However, it does not present immediate risks as significant as a family history of anesthetic complications.
Correct Answer is B
Explanation
B. Muscle spasms can sometimes be triggered or exacerbated by poor positioning or pressure on certain areas of the body. Realigning the client's position will help relieve muscle spasms by reducing pressure or tension on the affected muscles.
A. Adjusting the weight amount in traction may help alleviate pain and muscle spasms by reducing tension on the affected limb. However, realignment should be done first.
C. Muscle relaxants can help alleviate muscle spasms and associated pain by reducing muscle tone and tension. However, realignment should be done first.
D. Opioid analgesics are potent pain relievers that can effectively manage moderate to severe pain, including pain from muscle spasms. However, that should not be the first intervention.
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