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. Warm the insulin vial to dissolve any crystals that develop: Insulin should not be warmed as this can alter its efficacy. If crystals are present, the vial should be gently rolled, not heated.
B. Keep unopened insulin vials in the freezer: Insulin should not be kept in the freezer. Unopened vials should be stored in the refrigerator.
C. Store opened insulin vials at room temperature for up to 4 weeks: Opened insulin vials can be stored at room temperature for up to 4 weeks, which helps maintain its stability and usability.
D. Plan to eat a snack 6 hr after insulin administration: The timing of snacks should be aligned with insulin administration based on the type and dosage, not a fixed interval of 6 hours.
Correct Answer is D
Explanation
A. "I should consume fish once per week": While consuming fish is beneficial, particularly fatty fish high in omega-3 fatty acids, this alone is not a comprehensive strategy for preventing hypertension.
B. "With a BMI of 30, I should focus on maintaining my current weight": With a BMI of 30, which is classified as obese, the focus should be on reducing weight rather than maintaining it to help prevent hypertension.
C. "I should exercise for 30 minutes three times per week": The recommended amount of exercise for cardiovascular health is at least 150 minutes of moderate-intensity exercise per week, which is more frequent than three times per week.
D. "I should consume no more than 2,000 milligrams of sodium per day": This is correct as reducing sodium intake to no more than 2,000 milligrams per day is a key strategy for preventing and managing hypertension.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.