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","B","C"]
Explanation
These statements reflect the appropriate knowledge related to iron deficiency anemia. Iron-rich foods such as meat and beans can help increase iron levels in the body. Vitamin C aids in the absorption of iron, so taking a Vitamin C supplement can enhance iron absorption. Iron deficiency anemia is more common during pregnancy or menstruation due to increased iron demands.
However, increasing intake of dairy products alone does not address the iron deficiency. The statement about oral supplements not being as effective as monthly subcutaneous injections is incorrect, as oral iron supplements are commonly used to treat iron deficiency anemia and are effective in most cases.
Correct Answer is A
Explanation
Anaphylaxis is a severe and potentially life-threatening allergic reaction that can lead to a rapid drop in blood pressure, known as hypotension. This drop in blood pressure is a critical indicator of the severity of the reaction and the effectiveness of the treatment provided. The nurse needs to monitor the patient's blood pressure closely to ensure it stabilizes and returns to a safe range.
While oxygen saturation, heart rate, and orientation are also important parameters to assess, they are secondary to blood pressure in evaluating the effectiveness of treatment for anaphylaxis. Oxygen saturation can help determine the adequacy of oxygenation, heart rate can indicate the presence of tachycardia (which may be a sign of an ongoing reaction or hypoperfusion), and orientation can provide information about the patient's mental status and potential complications.
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