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.
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
D. Renal failure Correct Answer: B Rationale:
A. Stevens-Johnson syndrome is a severe allergic reaction that can occur with various medications, but it is not a common adverse effect of prednisolone.
B. Prolonged wound healing is a potential adverse effect of corticosteroids like prednisolone due to their immunosuppressive effects.
C. Hypotension is not a common adverse effect of prednisolone; rather, it can cause fluid retention and hypertension.
D. Renal failure is a rare adverse effect of prednisolone and is not typically monitored for in school-age children unless there are preexisting renal issues.
Correct Answer is B
Explanation
A. The nurse should not encourage flexion and extension of the neck, as this could cause further injury or damage to the spinal cord.
B. The nurse should reposition the client using a turning sheet to prevent skin breakdown and maintain alignment of the spine.
C. The nurse should assess the pin sites for infection at least once a day, not every other day.
D. The nurse should not tighten the screws on the halo device, as this could cause pressure ulcers or nerve damage. Only a provider can adjust the screws on the halo device.
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