A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

Remove the vest daily to inspect the client’s skin integrity.

Check that the halo jacket is snug against the client’s skin.

Provide range of motion to the client’s neck.

Monitor the client for an elevated temperature.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Removing the vest daily is not recommended as it can disrupt the alignment and stability provided by the halo fixation device.

Choice B rationale

The halo jacket should be snug but not too tight to avoid pressure sores and discomfort.

Choice C rationale

Providing range of motion to the neck is contraindicated as the halo fixation device is meant to immobilize the cervical spine.

Choice D rationale

Monitoring for an elevated temperature is crucial as it can indicate an infection, which is a common complication with halo fixation devices.

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Correct Answer is D

Explanation

Choice A rationale

Serosanguineous drainage is a normal finding at pin sites and does not indicate infection. It is a mixture of serum and blood and is expected during the initial healing phase.

Choice B rationale

Mild erythema around the pin sites can be a normal inflammatory response and does not necessarily indicate infection. It is important to monitor for other signs of infection.

Choice C rationale

Warmth at the pin sites can be a normal finding due to increased blood flow during the healing process. However, it should be monitored in conjunction with other signs of infection.

Choice D rationale

Fever is a systemic sign of infection and indicates that the body is responding to an infectious process. It is a critical finding that requires prompt attention and intervention.

A. Airway obstruction. B. Pneumonia. C. Pneumothorax. D. Fat embolism.

Correct Answer is D

Explanation

Choice A rationale

Airway obstruction is not a common complication of a femoral head fracture or skin traction.

Choice B rationale

Pneumonia can cause shortness of breath but is not the most likely complication in this scenario.

Choice C rationale

Pneumothorax is less likely in this context compared to a fat embolism.

Choice D rationale

Fat embolism is a known complication of fractures, especially long bone fractures like the femoral head. It can cause respiratory distress and dyspnea.

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A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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