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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. This is the correct intervention. Children with autism spectrum disorder may have difficulty with social interactions and may become overwhelmed by prolonged or intense interactions. Keeping staff visits brief allows for positive interactions while minimizing potential stress for the child.

B. Children with autism spectrum disorder often thrive on routines and predictability.
Varying daily routines can be distressing and may lead to increased anxiety.

C. Placing the child in a semi-private room may expose them to additional stimuli and potential social interactions, which can be overwhelming for a child with an autism spectrum disorder. A private room may provide a quieter and more controlled environment.

D. Background noise, such as from a television, can be overstimulating for a child with autism spectrum disorder. It is generally recommended to provide a quiet environment to help the child feel more comfortable and at ease.

A. Encourage the toddler to use an incentive spirometer. B. Place a cooling blanket on the toddler. C. Administer IV dantrolene sodium to the toddler. D. Administer aspirin to the toddler as needed for pain.

Correct Answer is A

Explanation

A. This is the correct intervention. Encouraging the toddler to use an incentive spirometer helps promote lung expansion and prevent atelectasis (collapsed lung tissue), which is
important for postoperative respiratory function.

B. Placing a cooling blanket on the toddler is not a standard intervention following routine surgery. It's important to monitor the toddler's temperature and use appropriate measures if they experience hyperthermia.

C. Administering IV dantrolene sodium is used for the treatment of malignant hyperthermia, a rare but life-threatening reaction to certain medications used during anesthesia. It is not a routine postoperative intervention.

D. Aspirin is generally not recommended for pain relief in children due to the risk of Reye's syndrome. Other pain management options, such as acetaminophen or ibuprofen, are typically used for postoperative pain in children.

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