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 B

Explanation

A. Absent nuchal rigidity is a positive sign in the context of managing bacterial
meningitis, but it alone does not determine when droplet precautions can be discontinued.

B. This is the correct answer. A negative cerebrospinal fluid (CSF) culture indicates that the bacterial infection has been effectively treated. Once the CSF culture is negative, the child is no longer considered contagious and can be removed from droplet precautions.

C. The initiation of antibiotics is an important step in treating bacterial meningitis, but the passage of time alone does not indicate when precautions can be discontinued. The
effectiveness of treatment is better determined by laboratory and clinical indicators.

D. The temperature is an important clinical parameter, but a temperature below 37.4° C (99.3° F) alone does not determine when droplet precautions can be discontinued. The decision is based on the resolution of the infectious process, as indicated by negative cultures.

A. "You can drink milk on an empty stomach." B. "You should consume flavored yogurt instead of plain yogurt." C. "You can replace milk with nondairy sources of calcium." D. "You might tolerate plain milk better than chocolate milk."

Correct Answer is C

Explanation

A. Drinking milk on an empty stomach is not recommended for individuals with lactose intolerance, as it can lead to more pronounced symptoms.

B. Flavored yogurts may contain additional sugars or additives that can exacerbate

symptoms in individuals with lactose intolerance. It is generally recommended to choose plain, unsweetened yogurt.

C. This is a correct instruction. There are various nondairy sources of calcium, such as fortified soy milk, almond milk, leafy green vegetables, and certain types of fish (like salmon and sardines).

D. Tolerability of plain milk versus flavored milk can vary from person to person. Some individuals may find one easier to tolerate than the other, but it is not a universal rule for everyone with lactose intolerance.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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