A nursing is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care?
Place the client in protective isolation.
Initiate the use of a PCA pump for pain control.
Keep the head of the bed at a 30° angle.
Reposition the client by log rolling every-4 hr.
The Correct Answer is D
A. Protective isolation is not routinely required for clients following scoliosis repair unless there is an underlying infection risk.
B. A PCA pump may be used for pain control, but it is not specific to post-scoliosis repair care.
C. Keeping the head of the bed at 30° is not required; positioning should focus on spinal alignment.
D. Log rolling the client every 4 hours is essential to maintain spinal alignment, prevent complications, and ensure safety following Harrington rod instrumentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["33"]
Explanation
- To calculate the gtt/min, use the formula: gtt/min = (volume in mL x drop factor) / time in min
- Plug in the values from the question: gtt/min = (100 mL x 10 gtt/mL) / 30 min - Simplify and solve: gtt/min = 1000 gtt / 30 min
- Divide both sides by 30: gtt/min = 33.33 gtt/min
- Round to the nearest whole number: gtt/min = 33 gtt/min
- The nurse should set the manual IV infusion to deliver 33 gtt/min
Correct Answer is C
Explanation
A. Bradycardia - This is a slow heart rate and is not a typical manifestation of acute osteomyelitis.
B. Numbness of toes on the affected foot - Numbness may be associated with nerve involvement but is not a classic manifestation of acute osteomyelitis.
C. Localized erythema - This is a characteristic sign of acute osteomyelitis. It indicates inflammation and infection in the affected area.
D. Hypothermia - This is a low body temperature, which is not typically associated with acute osteomyelitis.
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