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 C
Explanation
A. "I will have hot, dry, and flushed skin if I am having a heart attack": This statement is incorrect as it does not accurately reflect typical symptoms of a heart attack. Common symptoms include chest pain, shortness of breath, and possibly cold sweat, not hot, dry, and flushed skin.
B. "I will wait 30 minutes before taking action if I have heartburn": Waiting 30 minutes before taking action is incorrect for angina or heartburn. Immediate action is required for angina symptoms, and heartburn should be differentiated from angina by a healthcare provider.
C. "I will notify emergency response if I have sudden jaw pain": This statement is correct because sudden jaw pain can be a symptom of angina or a heart attack, indicating that immediate medical attention is needed.
D. "I will take four nitroglycerin sublingual tablets if I have chest pain": This statement is incorrect as taking four nitroglycerin tablets is excessive and could be harmful. The standard recommendation is to take one tablet every 5 minutes for up to three doses if chest pain persists, and then seek medical attention.
Correct Answer is B
Explanation
A. Discourage drinking with a straw: Drinking with a straw is not typically discouraged for stomatitis and may actually help the client avoid contact with painful areas in the mouth.
B. Recommend consumption of cold items: This is correct as cold items can provide soothing relief for the inflamed mucous membranes in stomatitis, helping to reduce discomfort.
C. Provide an alcohol-based mouthwash: Alcohol-based mouthwashes can irritate the mucous membranes further and should be avoided. Non-alcoholic, soothing mouthwashes or saline rinses are preferred.
D. Minimize the use of gravies and sauces: While gravies and sauces can be irritating due to their acidity or spiciness, the primary recommendation is to focus on soothing and non-irritating foods and oral care practices.
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