A nurse is planning care for a client who has just had spinal surgery. Which of the following actions should the nurse include in the plan of care?

Perform neurological checks every 2 hours.

Position the patient in a chair every 2 hours.

Inspect clear drainage on the spinal dressing.

Continue criminal checks.

Answer and Explanation

The Correct Answer is A

Choice A reason: Neurological checks are essential after spinal surgery to monitor for any changes or deterioration in the patient's neurological status. The frequency of these checks can vary based on the patient's condition, but a common standard is to perform them every 4 hours or sooner. However, in some cases, especially immediately post operation, checks may be required more frequently, such as every 2 hours, to ensure any complications are identified and managed promptly.

Choice B reason: While mobilization is an important aspect of postsurgical care to prevent complications such as deep vein thrombosis, positioning a patient in a chair every 2 hours may not be appropriate immediately following spinal surgery. The patient's mobility and pain level must be assessed, and activities should be gradually increased as tolerated.

Choice C reason: Inspecting the spinal dressing is important to identify signs of infection or complications. However, clear drainage is not typically expected and could indicate cerebrospinal fluid leakage, which requires immediate medical attention.

Choice D reason: The term "criminal checks" is not relevant to nursing care and seems to be a typographical error. The nurse's focus should be on clinical assessments and interventions related to the patient's health status.

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Correct Answer is B

Explanation

Choice A reason: The normal range for serum creatinine is indeed 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females. Serum creatinine is a waste product from the normal breakdown of muscle tissue. As kidneys become impaired for any reason, the serum creatinine level rises due to poor clearance by the kidneys.

Choice B reason: A GFR below 60 mL/min/1.73 m for three months or more is one of the criteria for the diagnosis of chronic kidney disease. GFR is a measure of how well the kidneys filter blood, and a lower GFR indicates poorer kidney function.

Choice C reason: Blood urea nitrogen (BUN) levels should indeed be between 7 and 20 mg/dL. BUN measures the amount of nitrogen in your blood that comes from the waste product urea. Urea is made when protein is broken down in your body. BUN levels can rise with the level of protein in your diet and your kidney function[^10^].

Choice D reason: An increase in serum potassium can indicate hyperkalemia, which may be a sign of acute kidney injury. Potassium is a critical electrolyte, and its levels are tightly regulated by the kidneys. High levels can lead to dangerous heart rhythms.

A. Enlarged distal extremities. B. Coarse facial features. C. Loss of color discrimination. D. Hepatomegaly. E. Moon face.

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

Explanation

Choice A reason: Enlarged distal extremities are a classic sign of acromegaly due to the overproduction of growth hormone, which affects the growth plates in the bones.

Choice B reason: Coarse facial features, including a protruding jaw and brow, enlarged nose, and thickened lips, are common in acromegaly due to the excessive growth of facial bones and soft tissues.

Choice C reason: Loss of color discrimination is not typically associated with acromegaly. This symptom may be related to other conditions affecting the optic nerve or the brain.

Choice D reason: Hepatomegaly, or an enlarged liver, can occur in acromegaly as a result of increased growth factor effects on the liver.

Choice E reason: Moon face is associated with conditions that lead to corticosteroid excess, such as Cushing's syndrome, but can also appear in acromegaly due to soft tissue swelling.

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A nurse is planning care for a client who has just had spinal surgery. Which of the following actions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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