A nurse is contributing to the plan of care for a client who has a halo vest after experiencing a cervical fracture 8 hr ago. Which of the following interventions should the nurse recommend including in the plan?

Reposition the client in bed using the halo ring.

Turn the client every 4 hr.

Loosen the screws while cleansing the pin sites.

Change the sheepskin lining under the device weekly.

Answer and Explanation

The Correct Answer is A

A. When caring for a client with a halo vest after a cervical fracture, it's essential to maintain spinal alignment and prevent further injury. Repositioning the client using the halo ring ensures that the cervical spine remains immobilized during movement, thereby reducing the risk of additional damage. This method provides controlled movement while preserving the integrity of the spinal column.
B. This is incorrect. While frequent turning is necessary to prevent complications such as pressure injuries, turning every 2 hours (not 4) is the standard for immobile clients.
C. Loosen the screws while cleansing the pin sites: This is incorrect as loosening the screws can compromise the stability of the halo vest. Pin site care should be done carefully without altering the tension of the screws.
D. Change the sheepskin lining under the device weekly: This is not frequent enough for proper hygiene and skin care; the lining should be checked more regularly and changed as needed to maintain skin integrity and comfort.

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Correct Answer is D

Explanation

A. "You may drink full liquids until 6 hours before the procedure": Typically, clients are instructed to follow a clear liquid diet and to stop drinking any liquids a few hours before the procedure, not full liquids.
B. "You will lie on your right side for the procedure": The client usually lies on their left side during a colonoscopy, not the right side.
C. "You should warm the liquid bowel preparation before drinking it": Bowel preparation solutions are generally not warmed; they are consumed as directed, often chilled to make them more palatable.
D. "You will be moderately sedated during the procedure": This is correct as colonoscopy usually involves moderate sedation to ensure client comfort and tolerance during the procedure.

A. Heart rate B. Respiratory effort C. Pain D. Blood pressure E. Mentation

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

Heart rate
• Hypovolemic Shock
o The elevated heart rate of 104/min is consistent with hypovolemic shock, where the body compensates for reduced blood volume by increasing heart rate to maintain cardiac output and perfusion.
• Pulmonary Embolism
o An increased heart rate can also occur with pulmonary embolism as the body responds to decreased oxygenation and impaired cardiac function.
Respiratory effort
• Hypovolemic Shock
o Increased respiratory rate of 24/min may be a compensatory mechanism in hypovolemic shock to enhance oxygen delivery to tissues despite reduced blood volume.
• Pulmonary Embolism
o Elevated respiratory rate can also be seen in pulmonary embolism due to impaired gas exchange and increased respiratory effort to compensate for decreased oxygen levels.
Pain
• Pulmonary Embolism
o Pain, particularly pleuritic chest pain, is a common symptom of pulmonary embolism and could be indicative of embolic obstruction in the pulmonary circulation.
Blood pressure
• Hypovolemic Shock
o The drop in blood pressure to 88/54 mm Hg is consistent with hypovolemic shock, where reduced blood volume leads to decreased perfusion and hypotension.
Mentation
• Hypovolemic Shock
o Altered mentation, such as restlessness or agitation, can be a sign of hypovolemic shock as decreased perfusion affects brain function and consciousness.
• Pulmonary Embolism
o Changes in mentation can also occur in pulmonary embolism due to hypoxemia or decreased perfusion to the brain.

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A nurse is contributing to the plan of care for a client who has a halo vest after experiencing a cervical fracture 8 hr ago. Which of the following interventions should the nurse recommend including in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

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