Examkin

Question

Difficulty: MediumReduction of Risk Potential

A nurse is planning care for a client who returned to the surgical unit 2 hours ago following a lumbar laminectomy. Which of the following nursing interventions should the nurse implement to reduce the risk of postoperative complications? Select all that apply.

  1. Maintain the client's spine in proper alignment by logrolling with assistance when turning.Answer
  2. B
    Elevate the head of the bed to a 60-degree angle to promote optimal lung expansion.
  3. Inspect the surgical dressing and the bedsheets directly underneath the client for clear drainage.Answer
  4. D
    Delegate the initial postoperative transfer and ambulation to the unlicensed assistive personnel (UAP).
  5. E
    Encourage the client to use an overhead trapeze bar to reposition themselves independently.
  6. Perform bilateral neurological assessments of the lower extremities every 2 to 4 hours.Answer

Answer

The appropriate interventions are maintaining spinal alignment by logrolling, inspecting the dressing and bedsheets for drainage, and performing frequent lower extremity neurological assessments.
The correct interventions focus on protecting the spinal surgical site, detecting early signs of neurological compromise, and identifying potential bleeding or cerebrospinal fluid leaks. Logrolling maintains spinal alignment, inspecting the dressing and bedsheets helps identify dependent pooling of blood or CSF, and frequent lower extremity neurological checks are vital for catching early signs of nerve compression.

Step-by-Step Solution

1
Analyze the client's surgical procedure and postoperative risks.
The client had a lumbar laminectomy, which involves the spine. Primary risks include spinal instability, nerve compression, hemorrhage, and cerebrospinal fluid (CSF) leak.
Understanding the specific surgical risks dictates the necessary nursing interventions for risk reduction.
2
Evaluate the positioning and mobility options.
Logrolling is identified as safe and necessary. High Fowler's positioning and trapeze bar use are identified as contraindicated due to promoting spinal flexion and twisting.
Maintaining proper spinal alignment is critical to prevent injury to the surgical site.
3
Evaluate the assessment and delegation options.
Frequent neurological checks and dependent dressing inspections are identified as correct. Delegating the initial ambulation to a UAP is identified as an unsafe delegation.
The RN must retain tasks requiring clinical judgment, such as initial postoperative assessments and mobility trials.

Key Concept

Postoperative Risk Reduction for Spinal Surgery
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic