A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take?
Position the client in a high-Fowler's position if clear drainage is noted on the dressing
Monitor sensory perception of the lower extremities.
Assist the client into a knee-chest position to manage postoperative discomfort.
Maintain strict bed rest for the first 48 hr postoperative.
The Correct Answer is B
A. Positioning the client in a high-Fowler's position if clear drainage is noted on the dressing is not a specific intervention for a laminectomy with spinal fusion. The nurse should follow the surgeon's specific postoperative orders regarding positioning and wound care.
B. Monitoring sensory perception of the lower extremities is a crucial nursing intervention after a laminectomy with spinal fusion. This is to assess for any signs of neurovascular compromise or nerve damage.
C. Assisting the client into the knee-chest position to manage postoperative discomfort is not a recommended position after a laminectomy with spinal fusion. The nurse should follow the surgeon's specific postoperative orders regarding positioning.
D. Maintaining strict bed rest for the first 48 hours postoperative is not typically indicated after a laminectomy with spinal fusion. Early mobilization and ambulation are often encouraged to prevent complications and promote recovery. The nurse should follow the surgeon's specific postoperative orders regarding activity and mobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["33"]
Explanation
- To calculate the gtt/min, use the formula: gtt/min = (volume in mL x drop factor) / time in min
- Plug in the values from the question: gtt/min = (100 mL x 10 gtt/mL) / 30 min - Simplify and solve: gtt/min = 1000 gtt / 30 min
- Divide both sides by 30: gtt/min = 33.33 gtt/min
- Round to the nearest whole number: gtt/min = 33 gtt/min
- The nurse should set the manual IV infusion to deliver 33 gtt/min
Correct Answer is ["32"]
Explanation
1. Determine the concentration of heparin in the solution:
- There are 25,000 units of heparin in 500 mL of D5W.
- Concentration = 25,000 units / 500 mL = 50 units/mL.
2. Calculate the required mL/hr for the desired infusion rate:
- The order is for 1600 units/hr.
- To find the mL/hr:
ML/HR=desired units/hr divided by unts/ml
=1600/50
=32ml/hr
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