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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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Providing the child with a warm blanket can help keep the child comfortable during the course of the illness but initiating airborne precautions is best intervention required.
B. Assessing the oral cavity for Koplik spots is not relevant for varicella, as Koplik spots are associated with measles.
C. Administering aspirin for fever is contraindicated in children with varicella due to the risk of Reye's syndrome.
D. The nurse should initiate airborne precautions, which include placing the child in a private room with negative air pressure, wearing a mask or respirator when entering the room, and limiting visitors and staff exposure. Airborne precautions prevent the transmission of varicella through small droplets that can remain suspended in the air for long periods of time.
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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