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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Restrict fluid intake: This would not be appropriate for hypernatremia, as fluid intake should generally be increased to help dilute serum sodium levels.
B. Restrict sodium intake: This is correct as reducing sodium intake helps manage hypernatremia by decreasing the amount of sodium in the bloodstream.
C. Administer a potassium supplement: Potassium supplementation is not indicated for hypernatremia and could lead to imbalances.
D. Administer a laxative: A laxative is not relevant for managing hypernatremia and does not address the underlying issue of high sodium levels.
Correct Answer is ["A","C","E"]
Explanation
A. Primary health problem: This is correct as it provides critical context for the client's current condition and the reason for the transfer.
B. Admission vital signs from 1 week ago: This is incorrect because recent vital signs are more relevant to the current status of the client; historical data from a week ago is less pertinent.
C. Scheduled times for dressing changes: This is correct as it is important for the receiving unit to know about ongoing care needs related to wound management.
D. Number of family members who have visited: This is incorrect as it does not pertain to the client's medical condition or immediate care needs.
E. Current medication prescriptions: This is correct as it is essential for the new care team to have information on the medications the client is currently taking to ensure continuity of care.
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