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 C
Explanation
Choice A reason: This choice is incorrect. Painless, raised purple nodules on the hard palate are not typically indicative of squamous cell carcinoma.
Choice B reason: This choice is incorrect. A small macule with a yellow-brown scale does not describe squamous cell carcinoma, which often presents as a firm nodule with a scaly crust.
Choice C reason: This is the correct choice. Squamous cell carcinoma can present as a firm nodule with a hard, scaly crust on the skin.
Choice D reason: Yellow white patches of growth on the tongue are more indicative of conditions such as oral leukoplakia, not squamous cell carcinoma.
Correct Answer is C
Explanation
Choice A reason: The blood should not be infusing for 5 hours as transfusions of packed RBCs should be completed within 2 to 4 hours to minimize the risk of bacterial growth and transfusion reactions.
Choice B reason: Medications should not be administered through the same IV line as blood products due to the risk of reactions and interactions.
Choice C reason: The packed RBCs are indeed connected by Tubing to normal saline, which is used to keep the line open and prevent clotting.
Choice D reason: The drip chamber should not be filled completely with blood as it is necessary to monitor the drip rate and to ensure that air does not enter the line.
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