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 C
Explanation
A. Hopscotch: Hopscotch typically requires the ability to hop on one foot and follow a structured set of rules, which may be too advanced for a 2-year-old. Toddlers are still developing coordination and motor skills, so activities like hopscotch are not age-appropriate.
B. Beginner sports: While toddlers can start developing coordination, organized sports (even beginner ones) usually require more advanced skills like following directions and teamwork, which may not be suitable for a 2-year-old.
C. Finger paints: Finger painting is an ideal activity for a 2-year-old. It encourages creativity, helps with fine motor skills, and is enjoyable for toddlers as they explore textures and colors. It is a developmentally appropriate form of play.
D. 30-piece puzzle: A 30-piece puzzle may be too complex for a 2-year-old. Toddlers typically enjoy simpler puzzles with larger pieces, which are easier for their developing fine motor skills and cognitive abilities. A simpler puzzle would be more appropriate.
Correct Answer is C
Explanation
A. Temperature: A temperature of 38.6°C (101.5°F) is elevated, but fever is a common symptom of bacterial pneumonia. It is important to monitor, but it is not the most critical finding in this case.
B. Skin condition: Hives and flushing could be signs of an allergic reaction to medication, but this is not immediately life-threatening. The nurse should report it, but the priority in this case is the oxygen saturation, which reflects the patient's respiratory status.
C. Oxygen saturation: Oxygen saturation of 93% is below the typical threshold of 95-100% and indicates mild hypoxemia. In a patient with bacterial pneumonia, low oxygen saturation signify worsening respiratory function. This requires immediate attention and reporting.
D. Lung sounds: Coarse crackles in the right lower lobe are expected in pneumonia due to lung consolidation. While it is important to monitor lung sounds, the priority is addressing the oxygen saturation level, which is directly related to the patient's ability to breathe effectively.
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