Prepare for your NCLEX-RN® exam with a clinical question about spinal surgery. Learn to recognize critical findings that require intervention by the nurse preceptor.
The newly graduated nurse on the medical unit is caring for a patient who is immobile following spinal surgery. Which statement by the newly graduated nurse requires intervention by the nurse preceptor?
A. “I’m going to put a heating pad on this reddened area of my client’s left leg.”
B. “I’ll be performing some passive range of motion exercises to help reduce stiffness and pain.”
C. “I’m going to ask another nurse to help me reposition my client every one to two hours.”
D. “Repositioning my client on a schedule will help prevent the formation of pressure injuries.”
Scroll down for the correct answer!
The correct answer to today’s NCLEX-RN® question is…
A. “I’m going to put a heating pad on this reddened area of my client’s left leg.”
Rationale: If redness, swelling, warmth, and pain develop in the lower limbs of a client who is immobile for long periods of time, the healthcare provider should be notified immediately because a thrombus may have formed in the veins of the leg. Further, redness indicates inflammation, and since heat can cause vasodilation and additional blood flow to the area, heat application would likely worsen these symptoms. Therefore, this statement requires intervention by the nurse preceptor.
Major Takeaway
Most clients can move on their own to get comfortable, but some will need the nurse’s assistance. Clients who may require assistance include those recovering from surgery, wearing a cast, are too weak to move due to an illness, are paralyzed, or unconscious. The nurse should remember that every client needs to reposition at least once every two hours. Some will need to be repositioned more frequently because periods of immobility can cause complications. One common complication of immobility is the development of pressure injuries. A client with early stages of pressure injuries has skin, usually over bony areas, turning white and shiny. Over time, the skin changes to red and no longer blanches (turns white) when pressed. This is followed by the area of skin breaking and the formation of a painful ulcer. These areas on the skin are vulnerable to further damage due to friction and shearing when they rub against the bedsheet or clothing. If redness, swelling, warmth, and pain develop in the lower limbs of a client who is immobile for long periods, the nurse should alert the healthcare provider immediately because a thrombus may have formed in the veins of the leg. Also, if the nurse notices any disconnected or leaking intravenous (IV) catheters, feeding tubes, colostomy bags, or draining tubes after repositioning the client, they should address it immediately to prevent further complications. Immobility can also cause tendons to tighten and shorten, leading to contractures in the joints that are stiff and painful. This can be prevented by regular repositioning and passive range of motion (ROM) exercises.
Incorrect Answer Explanations
B. “I’ll be performing some passive range of motion exercises to help reduce stiffness and pain.”
Rationale: This statement does not require intervention by the nurse preceptor. Immobility can cause tendons to tighten and shorten, leading to contractures in the joints that are stiff and painful. This can be prevented by regular repositioning and passive range of motion (ROM) exercises.
C. “I’m going to ask another nurse to help me reposition my client every one to two hours.”
Rationale: This statement does not require intervention by the nurse preceptor. Clients who are immobile should be repositioned at least once every two hours. However, some clients may need to be repositioned more frequently.
D. “Repositioning my client on a schedule will help prevent the formation of pressure injuries.”
Rationale: This statement does not require intervention by the nurse preceptor. One common complication of immobility is the development of pressure injuries, which can be mitigated by repositioning them on a timed schedule.
Want more NCLEX®-style practice questions? Try Osmosis by Elsevier today! Access your free trial and discover why millions of current and future clinicians and caregivers love learning with us.
Leave a Reply