A patient is started on prednisone therapy. Which of these goals should be given priority in the patient's plan of care?

The patient will maintain a moist oral mucosa.

The patient will increase physical mobility.

The patient will remain free of infection.

The patient will ingest a moderate potassium diet.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

While maintaining a moist oral mucosa is important, preventing infection takes precedence, as infections can lead to serious complications and compromise overall health.

Choice B rationale:

Increasing physical mobility is a valid goal, but infection prevention is more critical, especially when starting prednisone therapy, which can weaken the immune response.

Choice C rationale:

The priority lies in keeping the patient free of infection. Prednisone can suppress the immune system, making the patient more susceptible to infections that can have severe consequences.

Choice D rationale:

Ingesting a moderate potassium diet is important, but the prevention of infection takes precedence due to the potential for serious health risks associated with compromised immunity.

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Correct Answer is B

Explanation

Choice A rationale:

Absence of bowel sounds is not a priority in this situation as it is common for bowel sounds to be absent temporarily after surgery due to anesthesia and decreased peristalsis. It should be monitored, but it doesn't require immediate nursing action.

Choice B rationale:

A pulse rate of 150 per minute is a significant finding in a 10-year-old patient after surgery. Tachycardia can indicate pain, anxiety, hypovolemia, or other postoperative complications. Immediate nursing action is required to assess the cause and initiate appropriate interventions.

Choice C rationale:

Blood-tinged urine from the ureteral catheter might be expected after a surgical procedure involving the urinary system. While it requires monitoring, it is less urgent than addressing a high pulse rate in a postoperative child.

Choice D rationale:

Serosanguineous drainage on the incisional dressing is a normal finding in the immediate postoperative period. It indicates minor oozing of blood mixed with serous fluid. While it requires monitoring, it is not as concerning as the elevated pulse rate.

A. "You will be placed in halo traction.". B. "The nurses will use a log-roll technique when you are turned.". C. "You can have nothing by mouth for 72 hours.". D. "You will not be allowed to have visitors for 48 hours.".

Correct Answer is B

Explanation

Choice A rationale:

Placing the patient in halo traction is not applicable for a scoliosis correction surgery with Harrington rods. Halo traction is typically used for cervical spine injuries or deformities, not for scoliosis correction.

Choice B rationale:

The correct answer. After Harrington rod insertion, maintaining proper alignment is crucial to prevent complications. Using a log-roll technique when turning the patient helps maintain spinal alignment and prevent stress on the surgical site.

Choice C rationale:

Keeping the patient nothing by mouth for 72 hours is not typically necessary after scoliosis surgery. Clear fluids and a light diet are usually initiated shortly after surgery.

Choice D rationale:

Restricting visitors for 48 hours is not a standard practice after scoliosis surgery unless there are specific infection control concerns, which are not mentioned in the scenario.

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A patient is started on prednisone therapy. Which of these goals should be given priority in the patient's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 10-year-old patient has returned to her room after a surgical procedure. Which observation should take priority for nursing action?

Correct Answer is B

Explanation

A 13-year-old with severe scoliosis is admitted for insertion of Harrington rods. In preparing the patient for postoperative care, the nurse should provide which information?

Correct Answer is B

Explanation

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