A patient returns to the unit after having surgery with spinal anesthesia. What does the nurse know is/are the best action(s) to take to decrease the possibility of spinal headache? Select All That Apply

Administer morphine 1-2 mg IV

Ambulate the client as soon as she gets feelings back

Increase fluid intake

Encourage the patient to stay flat in bed

Position the client in high fowlers position

Answer and Explanation

Correct Answer : C,D

A. Administer morphine 1-2 mg IV

Administering morphine is not a preventive measure for spinal headaches. It may be considered for pain relief if the patient experiences discomfort after the effects of spinal anesthesia wear off.

B. Ambulate the client as soon as she gets feelings back

Ambulating the patient too soon after spinal anesthesia is generally not recommended. Staying in bed initially helps prevent complications like spinal headaches.

C. Increase fluid intake

Adequate hydration is important after spinal anesthesia to help maintain cerebrospinal fluid volume. Increasing fluid intake can reduce the risk of developing a spinal headache.

D. Encourage the patient to stay flat in bed

Remaining in a flat or slightly elevated position helps minimize cerebrospinal fluid leakage from the puncture site, reducing the likelihood of developing a spinal headache. This position is typically recommended for a specific duration after spinal anesthesia.

E. Position the client in high Fowler's position

Placing the patient in high Fowler's position (sitting upright) may increase the risk of cerebrospinal fluid leakage, potentially leading to a spinal headache. This position is not recommended for preventing spinal headaches after spinal anesthesia.

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Correct Answer is A

Explanation

A. Avoid caffeine-containing beverages before sleep

The highest priority teaching point to help relieve sleeplessness would be to advise the client to avoid caffeine-containing beverages before sleep. Caffeine is a stimulant that can interfere with the ability to fall asleep and maintain a restful sleep.

B. Perform strenuous exercise before bedtime

Strenuous exercise close to bedtime can actually stimulate the body and make it more difficult for the individual to relax and fall asleep. It is generally recommended to engage in exercise earlier in the day.

C. Drink lots of fluids before bedtime

Drinking excessive fluids before bedtime may lead to disrupted sleep as it can increase the need to wake up for bathroom trips during the night. It's advisable to limit fluid intake close to bedtime.

D. Eat a heavy meal before bedtime

Consuming a heavy meal before bedtime can cause discomfort and indigestion, potentially disrupting sleep. It is recommended to have a light, easily digestible meal if eating close to bedtime.

A. Give the child fluids and proceed to the emergency department. B. Call the poison control center and follow directions. C. Administer syrup of ipecac and monitor for vomiting. D. Have the toddler eat bread to absorb the substance.

Correct Answer is B

Explanation

A. Give the child fluids and proceed to the emergency department.
While giving the child fluids is generally important, proceeding to the emergency department without consulting poison control may not be the most appropriate initial action. Poison control can provide specific guidance based on the substance ingested.

B. Call the poison control center and follow directions.
The safest advice for a toddler who has ingested a small amount of household cleaning fluid is to call the poison control center and follow their directions. Poison control centers are staffed with professionals who can provide specific guidance based on the type and amount of the ingested substance. They can advise on the appropriate steps to take, such as whether immediate medical attention is needed or if monitoring at home is sufficient.

C. Administer syrup of ipecac and monitor for vomiting.
The use of syrup of ipecac is no longer recommended as a routine measure for ingested substances. It can have adverse effects and may not be effective for all substances. Consulting poison control for guidance is considered a more appropriate approach.

D. Have the toddler eat bread to absorb the substance.
The ingestion of certain substances may not be effectively addressed by having the toddler eat bread. The specific advice for management should come from poison control, which can provide evidence-based guidance.

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A patient returns to the unit after having surgery with spinal anesthesia. What does the nurse know is/are the best action(s) to take to decrease the possibility of spinal headache? Select All That Apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client measures to help relieve sleeplessness. Which would be the highest priority teaching point during the instructional session?

Correct Answer is A

Explanation

A toddler ingests a small amount of household cleaning fluid. What is the safest advice for the nurse to provide the caregiver?

Correct Answer is B

Explanation

A patient returns to the unit after having surgery with spinal anesthesia. What does the nurse know is/are the best action(s) to take to decrease the possibility of spinal headache? Select All That Apply

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