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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Fat embolism syndrome - This is characterized by respiratory distress, altered mental status, and petechial rash. It is not associated with increasing edema.

B. Pulmonary embolism - This occurs when a blood clot (usually from the legs) travels to the lungs and can present with symptoms like chest pain, shortness of breath, and rapid heart rate. It is not associated with increasing edema around a fracture site.

C. Acute compartment syndrome - This is a serious condition that occurs when increased pressure within a muscle compartment impairs blood supply, leading to tissue ischemia and necrosis. Increasing edema is an early sign of compartment syndrome.

D. Osteomyelitis - This is an infection of the bone and is not typically associated with increasing edema around a fracture site. It may present with local signs of infection like warmth, redness, and tenderness.

A. Mild erythema B. Serosanguineous drainage C. Fever D. Warmth

Correct Answer is C

Explanation

A. Mild erythema (redness) at the pin sites can be a normal finding due to the body's response to the presence of foreign objects. It may not necessarily indicate infection.

B. Serosanguineous drainage (a mixture of clear and bloody fluid) can also be a normal finding initially after the insertion of pins. It may not necessarily indicate infection.

C. Fever is a systemic response to infection. In a client with skeletal traction, fever can be an indication of an infection at the pin sites or a more systemic infection related to the traction device.

D. Warmth around the pin sites can be a normal finding due to the inflammatory response that occurs after pin insertion. It may not necessarily indicate infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications?

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Correct Answer is C

Explanation

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