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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Urine specific gravity measures the kidney's ability to concentrate urine. A normal range is typically 1.005–1.030. A value of 1.020 indicates adequate hydration and suggests that the patient is responding well to IV fluid therapy.

Choice B reason: Serum sodium levels reflect electrolyte balance. The normal range is 135–145 mEq/L. A level of 165 mEq/L is significantly elevated, indicating hypernatremia, which could be a sign of inadequate hydration and not a positive response to treatment.

Choice C reason: Hematocrit represents the proportion of blood volume occupied by red blood cells. Normal ranges are 38.3–48.6% for men and 35.5–44.9% for women. A hematocrit of 48% is at the upper limit of normal and does not specifically indicate the effectiveness of dehydration treatment.

Choice D reason: Blood urea nitrogen (BUN) levels can indicate renal function and hydration status. The normal range is 7–20 mg/dL. A BUN of 12 mg/dL is within the normal range and does not specifically reflect the patient's response to IV fluids for dehydration.

A. Are you taking a multivitamin? B. Have you had a recent influenza infection? C. Have you traveled overseas recently? D. Do you have a history of chronic alcohol abuse?

Correct Answer is B

Explanation

Choice A reason: Asking about multivitamin intake is not directly relevant to GBS, as the syndrome is not known to be caused by vitamin deficiencies or related to nutritional status.

Choice B reason: A recent influenza infection is relevant because GBS is often preceded by an infection, such as a respiratory or gastrointestinal viral infection. The immune system's response to this infection may mistakenly attack peripheral nerves, leading to GBS.

Choice C reason: While travel history is important in assessing exposure to infectious diseases, it is less specific than asking about recent infections. GBS can occur after exposure to certain viruses or bacteria, which can be contracted without overseas travel.

Choice D reason: Chronic alcohol abuse is a risk factor for various neurological conditions, but it is not a typical precursor to GBS. The syndrome is more commonly associated with immune responses to infections.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the patient is effectively responding to treatment?

Correct Answer is A

Explanation

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barre syndrome (GBS). Which of the following questions should the nurse ask the client?

Correct Answer is B

Explanation

A nurse is caring for an older adult client who has a WBC count of 2,000/mm after three rounds of chemotherapy. Which of the following actions should the nurse take?

A nurse is caring for a client who has a spinal cord injury and is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

A nurse is educating coworkers on how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply.)

A nurse is caring for a client who recently had surgery for the insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. Which of the following should the nurse use as the priority source of verification?

A nurse is assessing a client who has chronic bronchitis. Which of the following percussion sounds should the nurse expect?