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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Packed red blood cells should typically be infused within 4 hours to reduce the risk of bacterial contamination and ensure potency.
B. Dextrose 5% in water is not typically infused with packed RBCs; the focus is on administering blood products as prescribed.
C. Blood products are typically stored under controlled conditions and transfused promptly after verification and compatibility checks.
D. Filtered IV tubing is often used for blood transfusions to minimize the risk of air embolism and particle infusion, but it's not the primary intervention listed for the scenario.
Correct Answer is C
Explanation
A. Asking the child's parent to leave the room during the procedure may increase the child's anxiety and make the procedure more traumatic.
B. Performing the procedure in the unit's playroom may not provide the necessary equipment and sterile environment required for a venipuncture.
C. Applying a topical anesthetic cream helps reduce pain and discomfort during the venipuncture, promoting atraumatic care.
D. Explaining the procedure in detail to the child 3 hours prior to the procedure may increase anxiety and anticipation, making the procedure more traumatic.
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