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Question

Difficulty: HardBasic Care and Comfort

A client who is 12 hours postoperative following a lumbar spinal fusion is resting supine in bed. The client suddenly reports severe nausea and begins to actively vomit. Which action should the practical nurse implement first?

  1. A
    Rapidly elevate the head of the bed to a high-Fowler's position to utilize gravity in preventing aspiration.
  2. B
    Instruct the client to remain completely still while preparing to administer an intravenous push antiemetic.
  3. Request assistance to immediately logroll the client into a lateral position while maintaining straight spinal alignment.Answer
  4. D
    Assess the client's oxygen saturation and respiratory rate to determine the extent of airway compromise.

Answer

Request assistance to immediately logroll the client into a lateral position while maintaining straight spinal alignment.
The immediate priority for an actively vomiting client is securing the airway to prevent aspiration. Because the client has undergone a lumbar spinal fusion, the spine must remain perfectly straight to prevent surgical failure and nerve injury. Logrolling the client as a single unit onto their side with assistance effectively clears the airway while maintaining the mandatory spinal alignment.

Step-by-Step Solution

1
Identify the immediate physiological threat.
The client is actively vomiting while lying supine, creating a high risk for aspiration and airway obstruction (an Airway priority).
According to the ABCs (Airway, Breathing, Circulation), clearing the airway takes precedence over all other assessments and interventions.
2
Recognize the specific postoperative physical constraints.
The client has undergone a lumbar spinal fusion, which requires the spine to remain perfectly straight at all times.
Bending, twisting, or flexing the spine (such as sitting up) can disrupt the surgical hardware and cause severe nerve damage.
3
Synthesize the airway need with the positioning constraints to determine the safest action.
The nurse must logroll the client to the side using assistance.
Logrolling is the only basic care mobility technique that safely turns the client to clear emesis from the airway without bending the spinal column.

Key Concept

Postoperative Positioning and Airway Prioritization
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Topics

Basic Care and Comfort

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