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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The client's symptoms of bounding peripheral pulses, weight gain, pitting edema, and moist crackles bilaterally suggest fluid volume overload or fluid retention. Furosemide (Lasix) is a loop diuretic that helps to promote diuresis and reduce fluid volume. Administering the medication promptly can help address the client's symptoms and alleviate the fluid overload.

A. A 50-yr-old patient who uses exenatide (Byetta) and is complaining of acute abdominal pain B. A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL C. A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL D. A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%

Correct Answer is B

Explanation

A blood glucose level of 40 mg/dL indicates severe hypoglycemia, which is a medical emergency requiring immediate attention. Hypoglycemia can lead to confusion, altered mental status, seizures, and loss of consciousness if not treated promptly. Therefore, it is crucial to assess and intervene quickly to raise the patient's blood glucose level to a safe range.

While the other clients mentioned also require attention and appropriate care, the severity and immediate risk associated with severe hypoglycemia make it the priority situation. The nurse should initiate appropriate treatment for hypoglycemia, such as administering glucose or glucagon, and closely monitor the patient's response.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The health care provider has written the following orders for a client with bounding peripheral pulses, weight gain of 2 lb., pitting edema, and moist crackles bilaterally. Which order will the nurse complete first?

Correct Answer is C

Explanation

After a change-of-shift report, which client should the nurse assess first?

Correct Answer is B

Explanation

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The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?