A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?

Move the client up and down in bed by holding onto the halo traction device.

Ensure that there is space for one finger to fit between the vest and the client's skin.

Apply medicated powder under the vest to reduce itching.

Loosen or tighten the screws on the device as needed for the client's comfort.

Answer and Explanation

The Correct Answer is B

B. Ensuring that there is space for one finger to fit between the vest and the client's skin helps prevent skin breakdown and pressure injuries. The halo vest should fit snugly but not too tight to allow for proper circulation and comfort.
A. Moving the client by holding onto the halo traction device can disrupt the device's stability and potentially cause harm to the client.
C. Applying medicated powder under the vest can introduce foreign substances to the skin and may increase the risk of skin irritation or infection.
D. This should only be performed under the guidance of a healthcare provider.

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Correct Answer is B

Explanation

Feet circumduction increases the activity of calf muscles aiding in venous return. This prevents pooling of blood the deep venous system and hence lowers the risk of DVT

A, C and D have no role in the prevention of DVT

A. Increase potassium intake. B. Decrease protein intake. C. Increase phosphorus intake. D. Decrease carbohydrate intake.

Correct Answer is B

Explanation

Clients with nephrotic syndrome should have low to normal protein diet. This is because high protein diet damages the nephrons worsening the renal insufficiency in nephrotic syndrome.

High potassium, phosphorus diet is not recommended

Adequate carbohydrate intake is key.

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A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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