Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
10. A nurse is caring for a teenager immediately following surgical correction of severe scoliosis. Which interventions should the nurse expect to be part of the care plan? Select all that apply.
. Administer pain medication around the clock.
. Check circulation, sensation, and movement (CSM) frequently in extremities.
. Monitor urinary catheter output.
. Assist child to the chair once per shift.
. Assess bowel sounds daily.
Test-Taking Tip
The key phrase in the stem of the question is "immediately following" surgery. Select priorities that are part of the immediate postsurgical period.
Content Area: Child Health, Musculoskeletal; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is correct because the nurse can expect that the child will experience pain related to surgery, and pain medication needs to be provided on a schedule to prevent and treat pain. Answer 2 is correct because circulation, sensation, and movement (CSM) must be assessed often to detect potential neurological complications of spinal surgery. Answer 3 is correct because the child will have a urinary catheter in place and monitoring of the output is essential to protect against the complication of urinary retention. Answer 4 is incorrect because initial care of this child involves careful logroll turning, not placing the child in a chair as this could injure the surgical area. Answer 5 is incorrect because bowel sounds should be assessed frequently to monitor for possible paralytic ileus after surgery. Monitoring bowel sounds once daily is not sufficient.