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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A: Apply heat for 10 minutes every hour
Applying heat can help to relax the muscles and relieve tension, which can reduce pain. Heat therapy increases blood flow, which can aid in healing and reduce stiffness.
Choice B: Sleep in a side lying position with flexed knees
Sleeping in a side-lying position with flexed knees can help to maintain the natural curve of the spine and reduce strain on the back muscles. It's also recommended to use a pillow between the knees for additional support.
Choice C: Avoid prolonged sitting
Prolonged sitting can put pressure on the discs in your lower back and cause or exacerbate pain. It's recommended to take regular breaks to stand up and move around.
Choice D: Use padded shoe insoles
While padded shoe insoles can provide comfort and support for some people, there's no strong evidence to suggest that they can help to prevent or relieve back pain.
Choice E: Sleep on a soft mattress
Contrary to popular belief, a soft mattress may not be the best choice for people with back pain. A mattress that's too soft can cause your back to sink into the mattress, leading to poor sleep posture and discomfort. It's generally recommended to choose a mattress that provides good support and maintains the spine's natural alignment.
Correct Answer is B
Explanation
Choice A reason: An oral temperature of 38.2°C (100.76°F) is slightly elevated but can be expected postoperatively as the body responds to surgical stress. It is not necessarily an indication of a complication unless it rises significantly or is accompanied by other symptoms.
Choice B reason: The output of burgundy colored urine can indicate bleeding in the urinary tract, which is a potential complication after TURP. Normal urine color ranges from pale yellow to deep amber, depending on hydration levels. Burgundy colored urine postTURP could suggest the presence of blood, warranting further assessment and intervention.
Choice C reason: Feeling an urge to void despite having an indwelling urinary catheter can be uncomfortable but is not uncommon after TURP due to irritation of the bladder. It is not typically a sign of a complication unless accompanied by other symptoms such as pain or difficulty urinating once the catheter is removed.
Choice D reason: A pulse rate of 58/min is within the normal resting range for adults, which is typically 60100 beats per minute. A lower than average pulse rate postoperatively might be normal for the patient, especially if they are on medications like betablockers, or it could be a sign of a good fitness level.
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