Difficulty: Medium
Average Score: 85%
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
C
Rationale
The correct answer is C: Ensure two nurses logroll the adolescent every 2 hr. This action is crucial to prevent complications and maintain proper spinal alignment post-surgery. Logrolling involves turning the patient as a unit to prevent twisting or bending of the spine. It helps to avoid putting pressure on the surgical site and reduces the risk of injury. Maintaining the head of the bed at a 30┬░ angle (A) may be necessary for respiratory comfort but does not address the specific postoperative spinal care needed. Assisting the adolescent to ambulate 12 hr following surgery (B) may be too soon and could risk injury. Offering sips of water 4 hr following surgery (D) can be appropriate, but ensuring proper positioning and spinal care is more critical in the immediate postoperative period.