A patient experienced a cerebral spinal fluid leak after spinal surgery. The leak has just been treated with a blood patch. What is the nurse's priority action?
1. Administering a bolus of IV fluids
2. Positioning the patient on the left side
3. Initiating strict isolation procedures
4. Keeping the patient flat in bed for 2 hours
4
Rationale 1: Administration of increased fluids is not indicated. Rapid fluid administration could increase the cerebral spinal pressure and increase the risk of rupture of the patch.
Rationale 2: Positioning the patient on the left side is not indicated.
Rationale 3: Sterile procedures and sterile dressings should minimize the risk of infection. Strict isolation procedures are not indicated.
Rationale 4: Keeping the patient flat in bed for 2 hours will allow the blood patch to clot and not migrate to other parts of the spine, thus allowing a seal to be formed to minimize/stop the leaking of cerebral spinal fluids.
You might also like to view...
A seven-year-old girl has been diagnosed with rheumatic fever. The physician has talked with the parents and child and explained the disease and the planned medical treatment. Which statement by the parents needs further clarification?
1. "I understand rheumatic fever is a strep infection of the heart." 2. "My child will be on bed rest for several weeks." 3. "My child will be treated with aspirin and/or corticosteroids." 4. "Once my child has recovered, she will still need to be monitored for sequelae to the disease."
Within the communication process, the nurse realizes that encoding is:
a. a stimulus produced by a sender and responded to by a receiver. b. the person who intercepts the sender's message. c. a person who generates a message. d. the use of language or other signs and symbols for sending messages.
The physician orders multivitamins for the client. The client asks the nurse why she needs vitamins. What will the best teaching plan by the nurse include?
1. Small amounts of vitamins are needed for health. 2. Vitamins will heal many illnesses. 3. Vitamins are inorganic compounds that are not stored in the body. 4. Your body cannot synthesize most vitamins. 5. Vitamins are needed for growth and maintenance of normal metabolic processes.
A client asks the nurse when she should start having Pap tests to help detect cervical cancer?
A. "You should start the testing by age 21." B. "You should start testing by age 21 or if you begin using alcohol." C. "By age 21, but earlier if you have a family history of cancer." D. "By age 21 or earlier if you are smoking."