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 ["C","D","E"]
Explanation
The nurse explains that immobilizing a fracture will:
- Help align the bone fragments and reduce movement, which is crucial for proper healing. Immobilization can help maintain the stability of the fracture site, allowing the bones to knit together and heal.
- Help to minimize movement and subsequent pain. It provides support and reduces stress on the injured area, which can help alleviate discomfort and promote a more comfortable healing process.
- Help to minimize movement and reduce the risk of fat globules from bone marrow entering the bloodstream and causing a fat embolism, a potentially serious complication.
Preventing blood clots, preventing malignant hyperthermia, and immobilizing a fracture are not directly related. Preventing blood clots typically involves other measures such as early mobilization, elevation, and medication to prevent deep vein thrombosis. Malignant hyperthermia is a rare, potentially life-threatening reaction to certain medications used during anesthesia, and immobilization does not directly prevent it.
Correct Answer is ["B","C","D","E"]
Explanation
The initial bundle of care in sepsis includes the following:
- Obtain blood cultures: Blood cultures help identify the specific microorganism causing the infection, which is important for guiding appropriate antibiotic therapy.
- Administer broad-spectrum antibiotics: Early administration of antibiotics is crucial in sepsis to target the suspected or likely infectious organisms. Broad-spectrum antibiotics cover a wide range of potential pathogens until more specific information from culture results is available.
- Obtain lactate levels: Measuring lactate levels helps assess tissue perfusion and can be used as an indicator of the severity of sepsis. Elevated lactate levels are associated with tissue hypoperfusion and increased mortality.
- Administer IV fluid bolus: Early aggressive fluid resuscitation is an essential component of sepsis management. Administering intravenous fluids helps restore intravascular volume and improve tissue perfusion.
- Administration of vasopressors: Especially in the setting of hypotension and to maintain MAP above 65mmHg.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.