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 B
Explanation
A. "You should notify your provider if your testes are firm and egg shaped." This statement does not provide specific guidance on when or how to perform the examination. It also describes a normal shape of the testes.
B. This is the correct statement. Performing the testicular self-examination following a warm shower helps relax the scrotal tissue, making it easier to detect any abnormalities or changes.
C. "If you feel a hard lump, wait 1 month and retest yourself." This is not advisable. If a hard lump is detected during a testicular self-examination, the individual should promptly notify their healthcare provider for further evaluation.
D. "You should perform the examination once every other month." While regular
testicular self-examinations are important, it is generally recommended to perform them monthly, not once every other month.
Correct Answer is C
Explanation
A. Assisting the child into a supine position is contraindicated in acute epiglottitis. This can lead to airway obstruction. The child should be allowed to assume a position of comfort, which is typically sitting up and leaning forward.
B. While obtaining a throat culture may be indicated for diagnostic purposes, it is not the first priority in the care of a child with acute epiglottitis. The immediate concern is ensuring airway patency and providing appropriate respiratory support.
C. This is the correct action. Acute epiglottitis is a potentially life-threatening condition that can rapidly lead to airway obstruction. Initiating droplet isolation precautions helps protect healthcare providers and other patients from potential transmission of the causative organism (often Haemophilus influenzae type B).
D. Checking oxygen saturation every 4 hours is important for monitoring respiratory status, but in the case of acute epiglottitis, continuous monitoring of oxygen saturation is often necessary due to the risk of sudden airway obstruction. This action does not address the immediate priority of ensuring a patent airway.
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