A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care?

Offer sips of water 4 hr following surgery.

Assist the adolescent to ambulate 12 hr following surgery.

Maintain the head of the bed at a 30° angle.

Ensure two nurses logroll the adolescent every 2 hr.

Answer and Explanation

The Correct Answer is D

A.   Offering sips of water 4 hours following surgery may be too early and could increase the risk of postoperative complications such as nausea and vomiting.
B.   Assisting the adolescent to ambulate 12 hours following surgery may be too early depending on the surgical procedure and the adolescent's condition.
C.   Maintaining the head of the bed at a 30° angle is incorrect because this position increases pressure on the spinal cord and can cause complications.
D.   Logrolling the adolescent every 2 hours prevents spinal injury and promotes healing by keeping the spine in alignment

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Correct Answer is B

Explanation

A) An increase in potassium levels is not an expected finding with furosemide; instead, hypokalemia is a potential side effect.
B) Furosemide is a diuretic commonly used to decrease fluid retention and edema, so a decrease in peripheral edema would indicate the medication's effectiveness.
C) A decrease in cardiac output is not a desired effect of furosemide and may indicate worsening heart failure.
D) An increase in venous pressure would suggest venous congestion, which is not an indication of effective furosemide therapy.

A. Inject the immunizations into the deltoid muscle. B. Provide a pacifier coated with an oral sucrose solution prior to the injections. C. Use a 20-gauge needle for the injections. D. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before

Correct Answer is B

Explanation

A. Injecting the immunizations into the deltoid muscle may be appropriate for older children or adults but not for infants.
B. Providing a pacifier coated with an oral sucrose solution has been shown to reduce pain and distress during injections in infants, promoting atraumatic care.
C. A 20-gauge needle may cause more pain and tissue trauma in infants compared to a smaller gauge needle.
D. EMLA cream is not typically recommended for immunizations in infants as it requires time to take effect and may not provide adequate pain relief during the procedure.

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A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a school-age child who has heart failure and is taking furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?

Correct Answer is B

Explanation

A nurse is preparing to administer immunizations to a 3-month-old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?

Correct Answer is B

Explanation

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