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. Inserting sterile packing into the nares is not indicated in this situation. Clear fluid drainage from the nose may be cerebrospinal fluid (CSF), and packing could cause further complications.
B. Allowing the drainage to drip onto a sterile gauze pad is the appropriate initial action. Clear fluid drainage from the nose after a traumatic event may be CSF, which can indicate a skull fracture and damage to the meninges. Collecting the fluid on a sterile gauze pad can help confirm the presence of CSF.
C. Suctioning the nose with a bulb syringe is not recommended because it can introduce contaminants into the nasal passages and potentially worsen the injury.
D. Obtaining a culture of the specimen using sterile swabs is a consideration once the presence of CSF is confirmed. However, the initial priority is to identify and collect the clear fluid drainage.
Correct Answer is C
Explanation
A. Cabbage is not a significant source of calcium.
B. Potatoes are not a significant source of calcium.
C. Broccoli is a good source of calcium and can be advised to the client to increase in her diet.
D. Carrots are not a significant source of calcium.
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