A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?
Tighten the screws on the halo device one-quarter turn every 48 hr.
Assess the pin sites for infection once every other day.
Encourage flexion and extension of the neck.
Reposition the client using a turning sheet.
The Correct Answer is D
- A: Tighten the screws on the halo device one-quarter turn every 48 hr.
- Rationale: This action is incorrect because the screws on a halo device should not be adjusted by the nurse. The screws are typically set and secured by a healthcare provider, and any adjustments can compromise the integrity of the device and the stability of the cervical spine.
- B: Assess the pin sites for infection once every other day.
- Rationale: While it is important to monitor the pin sites for signs of infection, doing so once every other day may not be sufficient. Pin sites should be assessed at least once per shift to ensure early detection and management of any potential infection.
- C: Encourage flexion and extension of the neck.
- Rationale: This action is contraindicated for a client with a halo vest. The purpose of the halo vest is to immobilize the cervical spine to promote healing. Encouraging neck movement could cause further injury or delay healing.
- D: Reposition the client using a turning sheet.
- Rationale: This is the correct action. Using a turning sheet helps to reposition the client safely and effectively without exerting unnecessary pressure on the cervical spine. It also aids in preventing pressure ulcers and promotes comfort for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","H"]
Explanation
A. Instruct the parent to ensure the pneumococcal vaccine is current.
This is a preventive measure to reduce the risk of infections in individuals with sickle cell disease.
B. Give oral hydroxyurea.
Hydroxyurea is used to decrease the frequency of pain episodes in sickle cell disease.
C. Monitor oxygen saturation continuously.
Continuous monitoring of oxygen saturation is important to detect any potential respiratory complications.
D. Place the client on strict bed rest.
Bed rest helps to reduce the metabolic demands on the body and promotes healing.
E. Restrict oral intake.
During a sickle cell crisis, it's generally not necessary to restrict oral intake unless there are specific indications to do so, such as severe abdominal pain or vomiting that prevents the child from tolerating oral feeds.
F. Apply cold compresses to the affected joints. Administer meperidine IV for pain.
Cold compresses may exacerbate vaso-occlusion, and meperidine is not the first-line choice for pain management in sickle cell crisis due to potential neurotoxicity.
G. Administer meperidine IV for pain.
Meperidine has a relatively short duration of action, which may necessitate frequent dosing. This can lead to more fluctuations in pain control.
H. Administer folic acid as prescribed.
Folic acid supplementation is often recommended for individuals with sickle cell disease to support red blood cell production.
Correct Answer is C
Explanation
A. A blood pressure of 132/82 mm Hg in an adolescent is within the normal range for their age group. It does not require immediate reporting to the provider.
B. A respiratory rate of 30 breaths per minute in a 3-month-old infant is within the expected (typically 25-40 breaths per minute).
C. A heart rate of 68 beats per minute in an 18-month-old toddler is below the normal range (typically 70-110 beats per minute) and should be reported g to the provider.
D. A rectal body temperature of 37.3° C (99.1° F) in a school-age child is within the normal range (typically 36.5-37.5° C or 97.7-99.5° F). It does not require immediate reporting to the provider.
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