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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

While a JP drain can help limit bleeding and clots, its primary purpose is not to control bleeding. It is more focused on preventing fluid accumulation.

Choice B rationale

A JP drain does not eliminate the need for wound irrigations. Wound irrigations may still be necessary to clean the wound and prevent infection.

Choice C rationale

The primary purpose of a Jackson-Pratt (JP) drain is to prevent drainage from accumulating in the wound. By removing excess fluid, the JP drain helps reduce the risk of infection and promotes faster healing.

Choice D rationale

A JP drain is not used for medication administration. It is specifically designed to remove fluid from the surgical site.

A. Respiratory rate 18/min. B. Blood pressure 102/66 mm Hg. C. Yellow-green drainage on the surgical incision. D. Straw-colored urine from an indwelling urinary catheter.

Correct Answer is C

Explanation

Choice A rationale

A respiratory rate of 18/min is within the normal range for adults and does not typically require immediate intervention.

Choice B rationale

A blood pressure of 102/66 mm Hg is within the normal range for adults and does not typically require immediate intervention.

Choice C rationale

Yellow-green drainage from a surgical incision suggests infection and should be reported to the provider immediately for further evaluation and management.

Choice D rationale

Straw-colored urine from an indwelling urinary catheter is a normal finding and indicates adequate hydration and kidney function

View Question and Answer

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

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 who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?

Correct Answer is C

Explanation

A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the client understands the instructions?

A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?

The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?

A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings?

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?

A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)

A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?