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
Wound evisceration refers to the protrusion of internal organs or tissues through an open wound. In this case, with the separation of the wound and extrusion of the intestine through the opening, it is a clear indication of wound evisceration. It is a surgical emergency that requires immediate medical attention.
Wound dehiscence, on the other hand, refers to the separation or opening of a previously closed surgical incision or wound. It does not involve the extrusion of internal organs or tissues.
Wound infection refers to the presence of infectious microorganisms in the wound, leading to inflammation and other signs of infection.
Wound tunneling refers to the formation of narrow channels or tunnels within the wound, often caused by improper wound healing or infection.
Correct Answer is B
Explanation
Prednisone is a corticosteroid medication that can cause a range of side effects, including fluid retention, electrolyte imbalance, and increased blood pressure. A blood pressure reading of 148/94 mm Hg indicates hypertension, which may be related to the use of prednisone. It is essential to report this finding to the health care provider as it may require further evaluation and management, such as adjusting the medication dosage or initiating additional treatments to control blood pressure. The other information provided, such as stopping the medication, ankle edema, and not taking prescribed vitamin D, is relevant but does not pose an immediate threat to the patient's health compared to uncontrolled hypertension.
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