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 B
A: Placing the client in protective isolation is not necessary unless the client is immunocompromised or has another indication for isolation beyond the scoliosis repair.
B: A PCA (patient-controlled analgesia) pump allows the client to manage pain effectively by administering their own pain medication within prescribed limits, which is essential after the significant surgical intervention of scoliosis repair.
C: Keeping the head of the bed at a 30° angle is not specifically indicated for postoperative care following scoliosis repair with Harrington rod instrumentation. The position of the bed should be based on the client's comfort and specific postoperative orders.
D: Repositioning the client by log rolling every 4 hours is important to prevent complications such as pressure ulcers and to promote circulation, but it is not the priority intervention. Pain management postoperatively is crucial for client comfort, promoting mobility, and aiding in the recovery process.
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 D
Explanation
A. Vitamin B is a group of vitamins that play various roles in the body, including energy metabolism and nerve function. While it is important for overall health, it is not specifically known for wound healing.
B. Vitamin E is an antioxidant that helps protect cells from damage. While it is important for overall health, it is not specifically known for wound healing.
C. Folate (also known as vitamin B9) is essential for DNA synthesis and repair, as well as cell division. It is important for overall health, but it is not as directly associated with wound healing as vitamin C.
D. Correct. Vitamin C, also known as ascorbic acid, is essential for collagen synthesis, which is a key component of wound healing. It helps in the formation of scar tissue and the repair of damaged skin.
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