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. Glaucoma: Propranolol is not contraindicated in clients with glaucoma. It may, however, need to be used cautiously if the client has narrow-angle glaucoma due to potential systemic effects.
B. Asthma: This is correct as propranolol, a non-selective beta-blocker, can exacerbate asthma by causing bronchoconstriction, making it contraindicated in individuals with asthma.
C. Migraine headaches: Propranolol is often used to prevent migraine headaches and is not contraindicated in this condition. It is actually considered an effective treatment for migraine prophylaxis.
D. Irritable bowel syndrome: Propranolol is not contraindicated in irritable bowel syndrome. There are no specific concerns regarding propranolol's use with this condition.
Correct Answer is B
Explanation
A. Eat lighter, low-calorie foods first: While light foods can be easier to consume, prioritizing low-calorie foods may not address the client's nutritional needs. The focus should be on high-calorie, high-protein foods to maintain weight and strength.
B. Limit fluid intake during meals: This is correct as limiting fluid intake during meals can help prevent bloating and early satiety, which can be an issue for clients with COPD who have reduced appetite.
C. Eliminate dairy products: There is no general indication to eliminate dairy products unless the client has a specific intolerance or allergy. Dairy products are not universally problematic for clients with COPD.
D. Consume three regular meals daily: Clients with COPD may benefit from smaller, more frequent meals rather than three large meals to prevent feelings of fullness that can reduce appetite and increase shortness of breath.
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