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 A
Explanation
A. Changed mental status: This is a common indicator of a bladder infection in older adults, who may present with confusion or altered mental status instead of classic symptoms like dysuria or frequency.
B. WBC count 9,000/mm³ (5000 to 10,000/mm³): This WBC count is within the normal range and does not specifically indicate a bladder infection.
C. Diminished reflexes: This is not a typical indicator of a bladder infection and may suggest other neurological issues.
D. Temperature 37.3° C (99.1° F): This temperature is within the normal range and does not suggest an infection unless elevated or accompanied by other symptoms.
Correct Answer is A
Explanation
A. Leaning forward: This is correct as the client should be in a sitting position with arms resting on a table or a support to allow the lungs to expand and make the pleural space more accessible for the procedure.
B. Prone: This is incorrect because the prone position would not provide the necessary access to the pleural space and would be uncomfortable for the procedure.
C. Lithotomy: This is incorrect as the lithotomy position is used for gynecological procedures, not for thoracentesis.
D. Knees elevated: This is incorrect because elevating the knees is not a suitable position for thoracentesis and does not facilitate access to the pleural space.
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