A nurse is caring for a child who is in a halo vest for cervical traction. Which of the following actions should the nurse take?
Show the child's parent how to release tension on the bars.
Remove the vest for the child to sleep at night.
Check the child's pupillary response.
Apply a cervical collar if the child reports neck pain.
The Correct Answer is C
A. Show the child's parent how to release tension on the bars: The tension on the halo vest is adjusted by the healthcare provider, not by the parent. The nurse should not instruct the parent to release tension, as improper adjustments can lead to complications.
B. Remove the vest for the child to sleep at night: The halo vest should remain in place at all times, including during sleep, to maintain proper cervical traction and stabilization. Removing it may interfere with the healing process and cause further injury.
C. Check the child's pupillary response: Monitoring the pupillary response is important in a child with cervical traction to assess for any neurological changes. It helps identify signs of increased intracranial pressure or other neurological complications.
D. Apply a cervical collar if the child reports neck pain: The halo vest itself is designed to stabilize the neck, and the application of a cervical collar without provider guidance could interfere with the proper use of the traction system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["8"]
Explanation
Calculation:
- Calculate the desired dose in milligrams (mg) per administration.
Desired dose (mg) = 4 mg/kg × 16 kg
= 64 mg.
Available concentration of the medication = 40 mg/5 mL.
- Calculate the volume in milliliters (mL) to administer per dose.
Volume (mL) = Desired dose (mg) / (Available concentration (mg) / Available volume (mL))
= 64 mg / (40 mg / 5 mL)
= 8 mL.
Correct Answer is B
Explanation
A. Explain the risks associated with the procedure: Explaining risks is important, but it's the provider's responsibility to provide detailed information about risks, benefits, and alternatives. The nurse should ensure understanding.
B. Determine the parent's understanding of the procedure: The nurse's role is to ensure the parent understands the procedure. This includes confirming comprehension and providing clarification if needed.
C. Provide detailed information about the procedure to the parent: The nurse may provide general information, but the detailed explanation of the procedure, risks, and benefits should come from the provider.
D. Discuss the benefits of the procedure: Discussing benefits is part of informed consent, but it should be explained by the provider. The nurse’s role is ensuring understanding, not providing detailed explanations.
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