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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

“Our baby will sleep in our bed because I am breastfeeding.” Sharing a bed with a baby increases the risk of SIDS1.
Choice B is not the answer because removing blankets and toys from the crib is a recommended way to reduce the risk of SIDS2.
Choice C is not the answer because giving a baby a paciﬁer during naps and at bedtime can help reduce the risk of SIDS.
Choice D is not the answer because placing a baby on their back when sleeping is one of the most important measures to help protect against SIDS1.

A. BUN 50 mg/dL. B. Serum phosphorus 4.0 mg/dL. C. Serum potassium.8 mEq/L. D. Absence of proteinuria.

Correct Answer is A

Explanation

Chronic glomerulonephritis is a condition that causes inﬂammation of the glomeruli, which are tiny ﬁltering units in the kidneys.
This can lead to poor kidney function and an increase in waste products in the bloodstream.
Blood urea nitrogen (BUN) is a waste product that is normally ﬁltered by the kidneys and excreted in urine.
A BUN level of 50 mg/dL is higher than the normal range, indicating poor kidney function.
Choice B is incorrect because a serum phosphorus level of 4.0 mg/dL is within
the normal range for adults.
Choice C is incorrect because a serum potassium level of.8 mEq/L is within the normal range for adults.
Choice D is incorrect because proteinuria (the presence of protein in urine) is a
common ﬁnding in glomerulonephritis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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