A nurse is contributing to the care plan for a client who has a halo vest following a cervical fracture 8 hours ago. Which intervention should the nurse recommend for inclusion in the plan?
Loosen the screws while cleaning the pin sites.
Turn the client every 4 hours.
Change the sheepskin lining under the device weekly.
Reposition the client in bed using the halo ring.
The Correct Answer is C
Choice A rationale
Loosening the screws while cleaning the pin sites is not recommended. The screws are tightened to a specific pressure to ensure the halo vest is secure and provides the necessary immobilization.
Choice B rationale
The nurse should also provide education regarding changing positions at least every 2 hours to reduce pressure injuries.
Choice C rationale
Halo-vests are managed and monitored during spinal outpatient clinics and can be removed during this clinic appointment.
Choice D rationale
The halo ring should never be used to lift or reposition the client because it is directly attached to the skull. Pulling on the ring could cause serious injury or dislocation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering 5 mL of the available medication would only provide 12.5 mg of diphenhydramine, which is half the required dose. Therefore, this is not the correct choice.
Choice B rationale
The available medication is diphenhydramine syrup 12.5 mg/5 mL. To administer the required dose of 25 mg, the nurse would need to give 10 mL of the syrup. This is because 25 mg (required dose) divided by 12.5 mg (dose per 5 mL) equals 2. Therefore, 2 times 5 mL equals 10 mL. This is the correct choice as it provides the exact required dose.
Choice C rationale
Administering 15 mL of the available medication would provide 37.5 mg of diphenhydramine, which is more than the required dose. Therefore, this is not the correct choice.
Choice D rationale
Administering 20 mL of the available medication would provide 50 mg of diphenhydramine, which is double the required dose. Therefore, this is not the correct choice.
Correct Answer is D
Explanation
Obtaining an x-ray of the growth plate every 6 months is not a standard recommendation for preventing osteoporosis. Growth plates are only present in children and adolescents, and they close once a person reaches their full adult height.
Choice B rationale
Engaging in passive range-of-motion exercises is not typically recommended for preventing osteoporosis. Weight-bearing and resistance exercises are more beneficial for bone health.
Choice C rationale
Decreasing vitamin K in the diet is not recommended for preventing osteoporosis. Vitamin K is necessary for bone health, and a deficiency can actually increase the risk of osteoporosis.
Choice D rationale
Consuming vitamin D supplements daily is often recommended for preventing osteoporosis. Vitamin D is necessary for the body to absorb calcium, which is essential for bone health.
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