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 ["B","C","E","F","G"]

Explanation

Choice A rationale

Potassium level is not directly related to wound healing. While potassium is essential for overall cellular function, it does not have a direct impact on the wound healing process.

Choice B rationale

Pre-albumin level is a marker of nutritional status. Low pre-albumin levels indicate poor nutrition, which can delay wound healing. Adequate protein intake is essential for the synthesis of collagen and other proteins involved in the wound healing process.

Choice C rationale

History of diabetes mellitus can significantly delay wound healing. High blood glucose levels can impair immune function, reduce blood flow, and increase the risk of infection, all of which can delay the healing process.

Choice D rationale

History of hyperlipidemia is not directly related to wound healing. While hyperlipidemia can contribute to other health issues, it does not have a direct impact on the wound healing process.

Choice E rationale

Wound infection is a major factor that can delay wound healing. Infection can cause inflammation, tissue damage, and increased exudate, all of which can impede the healing process.

Choice F rationale

Decreased pedal perfusion indicates poor blood flow to the extremities. Adequate blood flow is essential for delivering oxygen and nutrients to the wound site, and poor perfusion can delay the healing process.

Choice G rationale

Fasting blood glucose levels are an indicator of blood sugar control. High fasting blood glucose levels can impair immune function and increase the risk of infection, both of which can delay wound healing.

A. Wound infection. B. Obesity. C. Altered mental status. D. Pain medication administration. E. Poor nutritional state.

Correct Answer is ["A","B","E"]

Explanation

Wound infection is a significant risk factor for dehiscence. Infections can weaken the wound edges and delay healing, increasing the likelihood of the wound reopening.

Choice B rationale

Obesity is a risk factor for dehiscence because excess adipose tissue can place additional stress on the wound, impair blood flow, and delay healing.

Choice C rationale

Altered mental status is not directly associated with an increased risk of dehiscence. While it may affect a patient’s ability to follow postoperative care instructions, it is not a primary risk factor.

Choice D rationale

Pain medication administration is not a risk factor for dehiscence. Pain management is essential for recovery and does not contribute to wound reopening.

Choice E rationale

Poor nutritional state is a risk factor for dehiscence because adequate nutrition is essential for wound healing. Malnutrition can impair the body’s ability to repair tissues and increase the risk of wound complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits Select the 5 findings that can cause delayed wound healing.

Correct Answer is ["B","C","E","F","G"]

Explanation

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Correct Answer is ["A","B","E"]

Explanation

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