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.
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Related Questions
Correct Answer is B
Explanation
A. Was hit by another soccer player on the field - This suggests a possible collision injury, which may result in various types of leg or foot injuries, but it doesn't specifically point to an ankle sprain.
B. Twisted his foot while running bases during a baseball game - This mechanism of injury is consistent with an ankle sprain. Twisting the foot during a sudden movement can cause stretching or tearing of ligaments around the ankle.
C. Has ankle pain after running a 16 km (10 mile) race - This suggests an overuse or strain injury, which could include various types of leg injuries, but it doesn't specifically point to an ankle sprain.
D. Dropped a 4.5 kg (10 lb) weight on his lower leg at a health club - This suggests a potential crush or impact injury to the lower leg, which may result in various types of leg injuries, but it doesn't specifically point to an ankle sprain.
Correct Answer is ["B","C","D"]
Explanation
A. Position weights against the foot of the bed: Incorrect. Weights in Buck's traction are typically hung freely over the end of the bed to provide the necessary countertraction. Placing them against the foot of the bed would not serve this purpose.
B. Examine the skin under the traction splint: Correct. It's important to regularly assess the skin underneath the traction splint to ensure there are no signs of pressure ulcers or skin breakdown.
C. Monitor peripheral pulses in the affected extremity: Correct. This is essential to ensure that blood flow to the extremity is not compromised by the traction.
D. Assess the temperature of the affected extremity: Correct. Monitoring the temperature helps in identifying any signs of impaired circulation.
E. Adjust the prescribed weights every shift: This is not something that should be done without specific orders from the healthcare provider. Adjusting the weights should be done based on the specific plan of care and provider's instructions.
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