Examkin

Question

Difficulty: MediumBasic Care and Comfort

A practical nurse is providing morning care and assisting a 72-year-old client with repositioning on the first postoperative day following a lumbar laminectomy. Which of the following actions should the nurse implement?

  1. Utilize a draw sheet with the assistance of a second staff member to roll the client's body as a single unit.Answer
  2. B
    Raise the head of the bed to a semi-Fowler's position before initiating the turn to improve respiratory effort.
  3. C
    Ask the client to reach across and pull on the opposite side rail to actively assist in turning their upper body.
  4. D
    Document any sudden onset of acute confusion observed during the care routine as a normal, age-related change.

Answer

The correct action is to utilize a draw sheet with the assistance of a second staff member to roll the client's body as a single unit.
The correct action involves logrolling the client. Following a lumbar laminectomy, the client's spine must be maintained in strict, straight alignment to prevent injury to the surgical site. Using a draw sheet and at least two staff members allows the client's shoulders and hips to turn simultaneously as a single unit without twisting.

Step-by-Step Solution

1
Identify the surgical procedure and its specific mobility precautions.
The client had a lumbar laminectomy, a spinal surgery which requires strict maintenance of spinal alignment to prevent surgical site injury.
Understanding the anatomical risks directly dictates safe physical repositioning techniques.
2
Evaluate the proposed positioning techniques for safety.
Logrolling (moving the body simultaneously as one continuous unit) is the only method that prevents spinal twisting or flexing.
Raising the head of the bed or having the client pull their upper body compromises spinal alignment.
3
Evaluate the assessment distractor regarding age and confusion.
Recognize that acute confusion is an abnormal finding (delirium) that requires clinical intervention, not an expected part of the aging process.
To ensure that basic care routines do not overshadow critical physiological assessments.

Key Concept

Logrolling Technique and Postoperative Spinal Alignment
Rate this question

Topics

Basic Care and Comfort

More questions from this topic