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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Related Questions
Correct Answer is C
Explanation
A. Russell's traction does not use skeletal pins. Skeletal traction involves the use of pins, wires, or screws inserted directly into the bone to stabilize a fracture.
B. Russell's traction does not involve the use of a pelvic girdle belt. Pelvic girdle belts are more commonly associated with some other forms of traction used for different purposes.
C. Russell's traction is specifically used for the treatment of a fracture of the femur, and it involves a sling placed under the knee to support and immobilize the affected leg.
D. Russell's traction is not used to decrease cervical muscle spasms. Cervical traction, using a cervical halter, is a separate form of traction used for cervical spine-related issues.
Correct Answer is ["A","C","D","E"]
Explanation
A. Place a compression bandage on the ankle.
- This helps reduce swelling and provides support to the injured area.
B. Apply heat to the ankle
- This action is not recommended for acute sprains as it can increase swelling. Cold packs or ice should be used initially to reduce inflammation.
C. Encourage rest.
- Rest is important to allow the ankle to heal properly and prevent further injury.
D. Elevate the ankle.
- Elevating the ankle helps reduce swelling by allowing fluid to drain away from the injured area.
E. Perform passive range-of-motion exercises to the ankle.
- Gentle range-of-motion exercises can help prevent stiffness in the ankle joint. However, it's important to perform these exercises within the limits of comfort and not force any movements.
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