A nurse is caring for a client who is postoperative placement of a halo vest to manage a cervical vertebral fracture.
Which of the following actions should the nurse take?
Encourage flexion and extension of the neck
Assess the pin sites for injection once every other day
Reposition the client using a turning sheet
Tighten the screw on the halo device once-quarter turn every 48 hr. .
The Correct Answer is C
Choice A rationale
Encouraging flexion and extension of the neck in a client with a halo vest for cervical vertebral fracture is not recommended. The purpose of the halo vest is to immobilize the neck to allow healing.
Choice B rationale
Assessing the pin sites for infection once every other day is not typically recommended. More frequent assessments are usually necessary to promptly identify any signs of infection.
Choice C rationale
Repositioning the client using a turning sheet is the correct action. This method of repositioning can help to prevent skin breakdown and pressure ulcers, which are potential complications for clients who are immobilized.
Choice D rationale
Tightening the screw on the halo device once-quarter turn every 48 hours is not typically recommended. Adjustments to the halo device should be made by a healthcare professional as needed based on the client’s condition and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Regular tuberculosis testing is recommended for children with HIV as they have a higher risk of developing tuberculosis due to their weakened immune system.
Choice B rationale
Doubling the child’s medications for the next 6 months is not a standard practice in HIV treatment. The dosage and regimen of antiretroviral therapy are carefully determined by healthcare providers based on the child’s specific needs and condition.
Choice C rationale
The risk of HIV transmission does not decrease after 2 weeks of zidovudine treatment. Antiretroviral therapy can reduce the viral load to undetectable levels, significantly reducing the risk of transmission, but this usually takes longer than 2 weeks to achieve.
Choice D rationale
Children with HIV do not need to repeat their childhood immunizations once they are in remission. The standard immunization schedule is generally followed for children with HIV, with some additional vaccines recommended due to their increased risk of certain infections.
Correct Answer is D
Explanation
Choice A rationale
Applying a warm pack to the injection site prior to administration is not recommended as it does not effectively reduce pain during immunizations.
Choice B rationale
Asking the parent to leave the room during the injections is not recommended as it may increase the infant’s anxiety and distress.
Choice C rationale
Administering the injections in the deltoid muscle is not recommended for a 2-month-old infant. The recommended site for intramuscular administration of immunizations in children under 18 months of age is the vastus lateralis (anterolateral thigh)3.
Choice D rationale
Administering the injections while the infant is breastfeeding is recommended. Breastfeeding during immunizations has been shown to significantly reduce pain and distress in infants.
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