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
Explanation
A. This is the correct statement. Children with HIV are at increased risk for tuberculosis (TB) infection. Therefore, regular testing for TB is an important part of their healthcare.
B. Doubling medications without specific guidance from the healthcare provider can be dangerous and is not recommended. It's important for the parent to follow the prescribed medication regimen as directed.
C. While zidovudine (AZT) is an important medication for HIV treatment, the statement is not accurate. The risk of transmission does not decrease after only 2 weeks of
treatment. It takes longer for the viral load to decrease significantly.
D. Children with HIV do not necessarily need to repeat their childhood immunizations once they are in remission. However, the timing and need for vaccinations may be
individualized based on the child's specific circumstances and immune status. This statement does not demonstrate a clear understanding of the teaching.
Correct Answer is D
Explanation
A. Placing the child in a protected environment for 48 hours is not a necessary measure for managing pertussis. Pertussis is transmitted through respiratory droplets, and standard precautions are typically sufficient.
B. Administering the pertussis vaccine is a preventive measure, but it is not a treatment for an active infection. In this case, the child already has pertussis, so administering the vaccine will not address the current illness.
C. Restricting oral fluids to 500 mL per day is not a recommended intervention for pertussis. Maintaining hydration is important, and fluid intake should be based on the child's needs.
D. This is the correct action. Reporting the diagnosis of pertussis to the public health department is a crucial step in preventing the spread of the disease. It allows for contact tracing and appropriate public health measures to be implemented to limit further
transmission.
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