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 D

Explanation

Choice A reason: Humidifying the client's room can help maintain mucous membrane integrity and prevent respiratory infections, which is crucial for a client with a low WBC count.

Choice B reason: Replacing the water in flower vases daily can prevent the growth of bacteria, reducing the risk of infection for an immunocompromised client.

Choice C reason: Cleaning dentures in a denture cup is a standard infection control practice that helps maintain oral hygiene and prevent infections.

Choice D reason: Serving cooked fruit with meals reduces the risk of transmitting infections that can be associated with raw fruits, which is important for a client with neutropenia.

A. Unable to discriminate words and letters. B. Motor retardation. C. Deficits in the right visual field. D. Poor impulse control.

Correct Answer is D

Explanation

Choice A reason: This choice is incorrect. A stroke involving the right cerebral hemisphere typically affects the left side of the body and can cause problems with spatial and perceptual abilities, not necessarily with language or discrimination of words and letters, which are more commonly associated with left hemisphere strokes⁸.

Choice B reason: Motor retardation is not specific to right hemisphere strokes. While right hemisphere strokes can cause weakness on the left side of the body, the term 'motor retardation' is not commonly used to describe this symptom⁸.

Choice C reason: This choice is incorrect because deficits in the right visual field would suggest a problem with the left cerebral hemisphere, not the right. A right hemisphere stroke typically causes problems with the left visual field⁸.

Choice D reason: This is the correct choice. Individuals with right hemisphere strokes may exhibit poor impulse control, as the right hemisphere is involved in judgment and behavior regulation⁸.

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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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Correct Answer is D

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