When providing care for a patient who has received spinal anesthesia, the nurse recognizes that ...

The answer to question 1

C
Position patients with spinal anesthetic supine, without elevation of the head, for up to 24 hours to prevent spinal headache from loss of cerebrospinal fluid. Increased IV or PO fluids aid the body in replacing cerebrospinal fluid.

The answer to question 2

D
Help a patient choose the most appropriate thermometer to use in the home based on the patient's dexterity, vision, and financial resources. For example, a patient with visual changes from glaucoma or retinopathy is able to read more easily a thermometer with a large digital display. The need for an oral, rectal, or axillary temperature depends on the patient's age and health status.

The answer to question 3

B
Conduct complete assessment of all vital signs. Compare findings with the patient's normal baseline. Continue assessing vital signs at least every 15 minutes until the patient's condition stabilizes.

The answer to question 4

C
If a mercury thermometer breaks, and it is not disposed of properly, the mercury gets into the air, posing a major health risk in the home (EPA, 2007). Educate patients about the environmental hazards associated with mercury in the home, and encourage patients to purchase mercury-free thermometers.

The answer to question 5

D
A leg unaffected by surgery can be exercised safely unless the patient has preexisting phlebothrombosis (blood clot formation) or thrombophlebitis (inflammation of the vein wall).
Instruct the patient to turn every 2 hours from side to back to the other side while awake. Have the patient continue to practice exercises at least every 2 hours while awake and repeat exercises 5 times. Instruct the patient to coordinate turning and leg exercises with diaphragmatic breathing, incentive spirometry, and coughing exercises.

The answer to question 6

C
Wounds to the groin area can result in a large amount of blood loss, which is not always visible. If bleeding should occur at the femoral artery puncture site, the patient should apply direct pressure immediately. At home, the patient may apply pressure with clean towels or linen. The patient should call the physician as soon as possible after homeostasis is established. The patient should call 9-1-1 as soon as possible after applying pressure to the site.

The answer to question 7

C
If the surgical incision is to be thoracic or abdominal, teach the patient to place a pillow over the incisional area and to place his hands over the pillow to splint the incision. The patient should begin by taking two or three slow, deep breaths inhaling through the nose and exhaling through the mouth. On the third inhale he should hold the breath to a count of 3 . The patient will then cough fully for two to three consecutive coughs without inhaling between coughs. Teach the patient to avoid using chest and shoulder muscles while inhaling.. The patient will do this 2 to 3 times every hour he is awake.

The answer to question 8

D
Monitor vital signs every 5 to 15 minutes (apical, distal rate, blood pressure). IV therapy and blood transfusions require a provider's order. Reinforce the dressing with tape as needed to prevent seepage. If the dressing is saturated, replace only the top layers so as not to disturb any clot formation at the wound site.

The answer to question 9

C
Although performing the diaphragmatic exercises in the upright position is ideal, the patient can still benefit from performing the exercises while laying flat. The upright position is preferred because it facilitates diaphragmatic excursion by using gravity to keep abdominal contents away from the diaphragm. It prevents tension on the abdominal muscles, which allows for greater diaphragmatic excursion.

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