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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Alcohol consumption, especially beer and spirits, is associated with an increased risk of gout attacks as it can elevate uric acid levels in the body. Limiting alcohol intake can help prevent gout attacks.
A. While adequate hydration is important for overall health, limiting fluid intake to 1 liter per day may not be appropriate, especially considering that hydration can help prevent gout attacks.
C. While aspirin is commonly used for pain relief, it is not typically recommended for gout management.
D. High-purine foods such as red meat, organ meats, and certain seafood can exacerbate gout symptoms by increasing uric acid levels in the body. Therefore, closely following a high-purine diet would likely worsen gout symptoms rather than improve them.
Correct Answer is ["C","D"]
Explanation
C. Education about the benefits of pain management, including how analgesics can improve postoperative activity levels by reducing pain and discomfort, helps to promote the patient's understanding and engagement in their own care.
D. Nurses should closely monitor the patient for both therapeutic effects and adverse effects of opioid administration when using PCA or any other opioid analgesic. Regular assessment allows for prompt identification and management of any complications or side effects.
A. Patient-controlled analgesia (PCA) is designed for the patient to self-administer pain medication according to their own needs and pain levels.
B. Opioid dosing should be individualized based on the patient's pain level and response to the medication. Some patients may require ongoing opioid analgesia for more than two days postoperatively, while others may be able to transition to alternative pain management strategies sooner.
E. Concerns about opioid addiction should not be assumed in all patients, especially those who have never received opioids before. Instead, the focus should be on assessing the patient's pain levels, response to pain medication, and any adverse effects.
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