Difficulty: Medium
Average Score: 63%
Simulated
A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care?
Correct answer
D
Rationale
The correct answer is D: Ensure two nurses logroll the adolescent every 2 hr. This is essential postoperative care for a patient with spinal instrumentation to prevent injury to the surgical site and reduce the risk of complications such as pressure ulcers and venous thromboembolism. Logrolling helps maintain spinal alignment and stability.
A: Offering sips of water 4 hr following surgery is not recommended as the patient may still be recovering from anesthesia and at risk of aspiration.
B: Assisting the adolescent to ambulate 12 hr following surgery may be too soon, as the patient may still be weak and in pain.
C: Maintaining the head of the bed at a 30┬░ angle is a general guideline for postoperative patients but is not specific to spinal surgery.
Therefore, the correct choice is D as it directly addresses the specific needs of a patient following scoliosis repair with spinal instrumentation.
A: Offering sips of water 4 hr following surgery is not recommended as the patient may still be recovering from anesthesia and at risk of aspiration.
B: Assisting the adolescent to ambulate 12 hr following surgery may be too soon, as the patient may still be weak and in pain.
C: Maintaining the head of the bed at a 30┬░ angle is a general guideline for postoperative patients but is not specific to spinal surgery.
Therefore, the correct choice is D as it directly addresses the specific needs of a patient following scoliosis repair with spinal instrumentation.