A nurse 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?
Reposition the client by log rolling every 4 hr.
Place the client in protective isolation.
Keep the head of the bed at a 30° angle.
Initiate the use of a PCA pump for pain control.
The Correct Answer is D
a. Log rolling is an appropriate technique to reposition a postoperative scoliosis repair patient as it minimizes stress on the spine and helps maintain spinal alignment. Patients need frequent repositioning to prevent pressure ulcers and promote comfort, but every 4 hours may not be frequent enough; typically, every 2 hours is recommended.
b. Protective isolation is not typically required for patients undergoing scoliosis surgery unless they have specific risk factors for infection (e.g., immunocompromised status). Standard postoperative care focuses on monitoring for infection at the surgical site rather than isolation unless indicated by the patient's condition.
c. While it’s important to elevate the head of the bed to assist with breathing and comfort, after scoliosis surgery, the head of the bed is generally elevated to 30-45° to facilitate lung expansion and reduce the risk of aspiration. However, it should be ensured that this angle does not compromise spinal alignment, especially in the early postoperative period.
d. The use of a patient-controlled analgesia (PCA) pump is an appropriate intervention for pain management after scoliosis surgery. It allows the patient to self-administer pain medication within prescribed limits, leading to more effective pain management, improved patient satisfaction, and potentially reduced need for supplemental analgesics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is d. Modify the environment.
Rationale for each choice:
Choice a. Improve the client's communication skills.
- Statement:While communication is important,it is not the priority for a child with hemiplegic cerebral palsy.
- Rationale:Hemiplegic cerebral palsy primarily affects motor skills,not communication abilities.While some children with hemiplegic cerebral palsy may have speech difficulties,it is not the most pressing concern in this case.Addressing environmental barriers to promote mobility and independence takes precedence.
Choice b. Provide respite services for the parents.
- Statement:Respite services can provide valuable support for parents,but they are not the priority in this case.
- Rationale:The focus of the care plan should be on the child's immediate needs and safety.Modifying the environment to enhance the child's functional abilities is crucial for their development and well-being.
Choice c. Foster self-care activities.
- Statement:Encouraging self-care is essential,but it requires a supportive environment.
- Rationale:Before promoting self-care activities,the nurse must ensure the child has the necessary accommodations and modifications in place to facilitate independence.
Choice d. Modify the environment.
- Statement:This is the priority goal for a child with hemiplegic cerebral palsy.
- Rationale:Modifying the home environment can significantly improve the child's mobility,safety,and ability to participate in daily activities.Examples of modifications include:
- Installing grab bars in the bathroom
- Widening doorways
- Removing tripping hazards
- Providing adaptive equipment such as special chairs or utensils
- Ensuring adequatelighting
Correct Answer is D
Explanation
Contact the provider to clarify the dosage and frequency of medication administration.
The nurse should always verify the dosage and frequency of medication administration with the provider before administering any medication to ensure the safety and well-being of the infant.
Choice A is not an answer because the nurse should verify the dosage and frequency with the provider before administering any medication.
Choice B is not an answer because the nurse should verify the dosage and frequency with the provider before administering any medication.
Choice C is not an answer because waiting and monitoring the infant’s symptoms does not address the need to verify the dosage and frequency of medication administration with the provider.
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