The nurse is caring for an adolescent diagnosed with scoliosis who just arrived to the floor from the recovery room after a Spinal fusion surgery. The nurse should question which physician order?
Out of bed three times daily & ad lib.
Assess neurological status every 4 hours.
Logroll only to change position.
Monitor vital signs every 4 hours.
The Correct Answer is A
After spinal fusion surgery, it is important to limit the patient's activity and movement to allow for proper healing and to prevent complications. The order to have the patient out of bed three times daily and ad lib (as desired) is not appropriate immediately after surgery.
The other orders listed are appropriate for the postoperative care of a patient who has undergone spinal fusion surgery:
- Assess neurological status every 4 hours: This is important to monitor for any changes in neurological function, which could indicate complications such as nerve damage or spinal cord compression.
- Logroll only to change position: Logrolling is a technique used to move patients with spinal fusion surgery while keeping their spine aligned and minimizing stress on the surgical site. This order is appropriate to ensure proper positioning and prevent injury to the surgical area.
- Monitor vital signs every 4 hours: Monitoring vital signs helps to assess the patient's overall condition and detect any signs of complications such as bleeding or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Acute renal failure is characterized by a sudden decline in kidney function, resulting in the inability of the kidneys to adequately filter waste products and maintain fluid and electrolyte balance. Monitoring urine output is essential in assessing kidney function and determining the severity of renal failure. A decrease in urine output or anuria may indicate worsening renal function and the need for immediate interventions.
Assessing electrolyte levels, such as sodium, potassium, calcium, and phosphorus, is crucial because renal failure can disrupt the balance of these electrolytes in the body. Imbalances can lead to complications such as electrolyte abnormalities, cardiac dysrhythmias, and neuromuscular disturbances. Prompt identification and management of electrolyte imbalances are essential in preventing further complications and supporting optimal patient outcomes.
Correct Answer is A
Explanation
A. Notify the surgeon that the informed consent process is not complete.The nurse should inform the surgeon because the surgeon is responsible for ensuring that the patient has adequate information and understands the procedure. It is not appropriate for the nurse to proceed with the consent process if the patient has questions or uncertainties.
B. Notify the operating room nurse to give a more complete explanation of the procedure.While the operating room nurse plays a role in the surgical process, it is the surgeon’s responsibility to provide a complete explanation of the procedure.
C. Provide a thorough explanation of the planned surgical procedure.While it’s important to provide information, the nurse is not authorized to explain the surgical procedure in detail. The surgeon should explain the surgery, as they have the training and knowledge to address all aspects of the procedure and answer any specific questions.
D. Give the prescribed preoperative antibiotics and withhold sedative medications.Administering preoperative medications, including antibiotics, without completed informed consent would be inappropriate. The patient must fully understand the procedure and consent to it before any medications are given.
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