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
A. Offering a prize for not crying may inadvertently reinforce crying as an expectation.
B. This statement is not accurate because the medicine might not fix the problem or make the child feel better immediately.
C. Assuring the child that they will only feel a little stick is not honest because the injection might hurt more than a little stick, and lying to the child can damage the trust between the nurse and the child.
D. Allowing the child to choose the injection site allows the child to have some control and autonomy over the situation, which can reduce anxiety and fear.
Correct Answer is C
Explanation
A. Examining the child for skin irritation at the cast edges is important to prevent complications, but it is not the priority over monitoring for circulation and potential complications.
B. Restricting strenuous activities is important for preventing damage to the cast, but it is not the priority over monitoring for circulatory compromise.
C. Monitoring for pallor or swelling in the child's affected hand is the priority because it indicates potential circulatory compromise, which is a critical concern following cast application.
D. Using a hair dryer on a cool setting to relieve itching is a helpful suggestion, but it is not the priority over monitoring for potential complications.
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