An adolescent is in the postoperative recovery area after surgery for scoliosis repair involving placement of a Harrington rod. What is a priority nursing action?
1. Evaluate for presence of bowel sounds.
2. Provide assistance when getting out of bed to use the bathroom.
3. Use log-rolling procedure when changing positions.
4. Monitor skin for development of pressure ulcers.
Answer: 3
Using log-rolling procedure is the most important nursing action immediately after surgery to prevent damage to the fusion and instrumentation. Typically, the client is kept flat in bed for the first 12 hours and is not ambulatory until the second or third postoperative day. Monitoring the skin for development of pressure ulcers is certainly a nursing action, but not an immediate priority, but more of an issue if the client is immobile for a long period of time. Bowel sounds are normally diminished or absent immediately after general surgery, so assessment for the presence of bowel sounds would not be a priority.
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