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 B
A: Placing the client in protective isolation is not necessary unless the client is immunocompromised or has another indication for isolation beyond the scoliosis repair.
B: A PCA (patient-controlled analgesia) pump allows the client to manage pain effectively by administering their own pain medication within prescribed limits, which is essential after the significant surgical intervention of scoliosis repair.
C: Keeping the head of the bed at a 30° angle is not specifically indicated for postoperative care following scoliosis repair with Harrington rod instrumentation. The position of the bed should be based on the client's comfort and specific postoperative orders.
D: Repositioning the client by log rolling every 4 hours is important to prevent complications such as pressure ulcers and to promote circulation, but it is not the priority intervention. Pain management postoperatively is crucial for client comfort, promoting mobility, and aiding in the recovery process.
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Related Questions
Correct Answer is C
Explanation
A. Twisting at the waist while lifting or moving an object can strain the back muscles and potentially lead to injury. The nurse should advise against this.
B. Relaxing the abdominal muscles while lifting an object can lead to inadequate support for the spine, potentially causing further strain or injury. The nurse should instruct the client to engage the abdominal muscles for stability.
C. Correct. Bending at the knees when picking up an object helps distribute the weight more evenly and reduces strain on the back muscles. This is a safe and recommended technique for lifting.
D. Holding an object away from the body while lifting it can increase the strain on the back muscles. The client should be advised to keep the object close to their body for better support and balance.
Correct Answer is B
Explanation
A. Increasing the client's protein intake is important for overall healing, but it is not the top priority in the acute phase of osteomyelitis. The immediate priority is to administer antibiotics to address the infection.
B. This is the correct answer. Administering antibiotics is the top priority in the treatment of acute osteomyelitis. Timely administration of appropriate antibiotics is crucial in eradicating the infection and preventing further complications.
C. Providing the client with antipyretic therapy (to reduce fever) is important, but it is secondary to administering antibiotics. The underlying infection must be addressed first and foremost.
D. Teaching relaxation breathing to reduce pain may be beneficial for the client's comfort, but it is not the priority intervention. Controlling the infection with antibiotics takes precedence.
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