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.

Answer and Explanation

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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Correct Answer is ["A","C","D"]

Explanation

A. Assessing the temperature of the affected extremity is important because changes in temperature could indicate circulation problems, which are a concern with traction. Assessing temperature helps in detecting any potential issues early on.

C. Skin integrity is crucial as traction can put pressure on the skin, potentially leading to pressure ulcers or skin breakdown. Regular examination helps in detecting any signs of skin irritation or breakdown early so that appropriate interventions can be initiated.

D. Traction can sometimes impede circulation to the affected limb, leading to complications such as compartment syndrome. Monitoring peripheral pulses helps in detecting any circulation problems promptly.

B. Adjusting the prescribed weights is not typically within the nurse's scope of practice, as the weights are determined by the physician and should not be altered without specific orders.

E. Positioning the weights against the foot of the bed is incorrect; they should hang freely to maintain effective traction.

A. The patient reports abdominal pain when ambulating. B. The patient has fluid intake 600 mL greater than the output. C. The patient's calf is swollen and warm to touch. D. The patient's temperature is 100.3° F (37.9° C).

Correct Answer is C

Explanation

C. The patient's calf being swollen and warm to touch is concerning for a possible deep vein thrombosis (DVT), a clot formation in the deep veins of the leg. DVT is a serious complication post-surgery that requires immediate attention to prevent the clot from dislodging and causing a pulmonary embolism (PE), which can be life-threatening.

A. Abdominal pain after a total abdominal hysterectomy is common and can be expected due to the surgical incision and manipulation of abdominal tissues.

B. Fluid balance is important postoperatively to prevent complications like dehydration or fluid overload. A significant imbalance, with intake substantially greater than output, could indicate issues which may require intervention. However, this is not as urgent as a client with likely DVT.

D. A slight increase in temperature is common in the immediate postoperative period due to the body's response to tissue injury. While it could indicate infection, it's not necessarily alarming on its own.

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A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

Correct Answer is C

Explanation

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