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 C

Explanation

C. Erythrocyte sedimentation rate (ESR) is a blood test that measures the rate at which red blood cells settle in a tube of blood over time. ESR levels are commonly elevated in inflammatory conditions such as RA.

A. Rheumatoid factor (RF) is an autoantibody commonly found in individuals with rheumatoid arthritis (RA). However, monitoring RF levels is not typically used to evaluate the effectiveness of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) in managing RA symptoms.

B. ANA levels are not typically monitored to evaluate the effectiveness of aspirin or NSAIDs in managing RA symptoms.

D. Monitoring WBC count is important for assessing overall health and detecting infections but it is not specific to evaluating the effectiveness of aspirin or NSAIDs in managing RA symptoms.

A. Muscle spasms B. Hip pallor C. Leg abduction D. Leg lengthening

Correct Answer is A

Explanation

A. Muscle spasms can occur in response to the hip fracture as the body attempts to protect the injured area. Spasms may cause pain and muscle rigidity in the affected hip.
B. Pallor refers to paleness of the skin. While hip fractures can result in various signs and symptoms such as pain, swelling, and bruising, hip pallor specifically is not typically associated with a hip fracture.
C. Leg abduction refers to moving the leg away from the midline of the body. In the case of a hip fracture, the affected leg may be held in adduction (closer to the midline) due to pain and muscle guarding.
D. Leg lengthening is not typically associated with a hip fracture. In fact, a hip fracture can often lead to apparent leg shortening due to displacement or angulation of the fractured bone.

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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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