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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bradycardia - This is a slow heart rate and is not a typical manifestation of acute osteomyelitis.
B. Numbness of toes on the affected foot - Numbness may be associated with nerve involvement but is not a classic manifestation of acute osteomyelitis.
C. Localized erythema - This is a characteristic sign of acute osteomyelitis. It indicates inflammation and infection in the affected area.
D. Hypothermia - This is a low body temperature, which is not typically associated with acute osteomyelitis.
Correct Answer is C
Explanation
A. Fat embolism syndrome - This is characterized by respiratory distress, altered mental status, and petechial rash. It is not associated with increasing edema.
B. Pulmonary embolism - This occurs when a blood clot (usually from the legs) travels to the lungs and can present with symptoms like chest pain, shortness of breath, and rapid heart rate. It is not associated with increasing edema around a fracture site.
C. Acute compartment syndrome - This is a serious condition that occurs when increased pressure within a muscle compartment impairs blood supply, leading to tissue ischemia and necrosis. Increasing edema is an early sign of compartment syndrome.
D. Osteomyelitis - This is an infection of the bone and is not typically associated with increasing edema around a fracture site. It may present with local signs of infection like warmth, redness, and tenderness.
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