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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["69"]
Explanation
Convert the weight from pounds to kilograms
190 lb * (1 kg / 2.2046 lb) = 86.183 kg (rounded to three decimal places)
The recommended dietary allowance (RDA) of protein:86.183 kg * 0.8 g/kg = 68.946 g/day
Rounding to the nearest whole number, the client should receive approximately 69 grams of protein daily.
Correct Answer is D
Explanation
D. After treatment for primary syphilis, it is essential for the client to have follow-up blood tests to monitor their response to treatment and ensure that the infection has been adequately treated. The follow-up blood tests are typically performed at 3, 6, and 12 months after treatment to check for resolution of the infection.
A. Syphilis is caused by a bacterial infection, not a virus. Therefore, antiviral medications are not effective for treating syphilis.
B. Cryotherapy, which involves freezing off warts or abnormal tissue, is not a treatment for syphilis.
C. Monitoring for 15 minutes after receiving each medication dose is a standard precaution for certain medications, such as vaccines or allergy injections, to monitor for any immediate adverse reactions. However, it is not necessary for syphilis.
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