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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering diphenhydramine with food does not specifically address the adverse effect of dry mouth. While taking the medication with food can help reduce gastrointestinal side effects, it does not alleviate dry mouth.
Choice B rationale
Chewing on sugarless gum or sucking on hard candies can help stimulate saliva production and alleviate dry mouth. This is an effective and simple measure to manage the adverse effect of dry mouth associated with diphenhydramine.
Choice C rationale
Placing a humidifier at the bedside can help maintain moisture in the air, but it is not the most effective measure for managing dry mouth. Chewing gum or sucking on candies directly stimulates saliva production, providing more immediate relief.
Choice D rationale
Discontinuing the medication and notifying the provider is not necessary for managing dry mouth. Dry mouth is a common and manageable side effect of diphenhydramine. Simple measures like chewing gum or sucking on candies are usually sufficient to alleviate this symptom
Correct Answer is ["0.5"]
Explanation
Step 1 is (10 mg ÷ 20 mg/mL) = 0.5 mL. The nurse should administer 0.5 mL per dose. .
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.