A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider?

May operate a motor vehicle when no longer taking analgesics.

May place a small pillow under the head when sleeping.

Increase intake of fiber-rich foods.

Take tub baths instead of showers.

Answer and Explanation

The Correct Answer is A

A halo device is a type of external fixation device that immobilizes the cervical spine after an injury or surgery. The device consists of a metal ring attached to four metal rods that are secured to a vest worn by the client. The device limits the movement of the head and neck, which can impair the client's ability to drive safely. The nurse should clarify with the provider if the client can operate a motor vehicle while wearing the halo device, as this may pose a risk for injury to the client and others on the road.

Placing a small pillow under the head when sleeping, increasing intake of fiber-rich foods, and taking tub baths instead of showers are all appropriate instructions for a client with a halo device

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Correct Answer is D

Explanation

Thrombocytopenia is a condition where the blood has a low platelet count, which can impair blood clotting and increase the risk of bleeding. Heparin is an anticoagulant that prevents blood clots from forming or growing, but it can also cause or worsen thrombocytopenia and bleeding.

Therefore, heparin is contraindicated for clients who have thrombocytopenia or are at risk of developing it. The other conditions are not contraindications to receiving heparin.

A. "I will have to wait 2 months before additional saline can be added to my breast expander." B. "I should expect less than 25 mL of secretions per day in the drainage devices." C. "I will keep my left arm flexed at the elbow as much as possible." D. "I will perform strength-building arm exercises using a 15-pound weight."

Correct Answer is B

Explanation

The client should expect less than 25 mL of secretions per day in the drainage devices before they are removed, usually within 7 to 10 days after surgery. This indicates that the wound is healing and there is no excessive fluid accumulation in the surgical site. The other statements are incorrect and indicate a need for further teaching. The client should not wait 2 months before additional saline can be added to the breast expander, as this may delay the reconstruction process and increase the risk of infection or contracture.

The client should keep the left arm elevated on a pillow and avoid flexing it at the elbow, as this may impair lymphatic drainage and cause edema or pain. The client should perform gentle range-of-motion exercises with the left arm and avoid lifting heavy objects such as a 15-pound weight, as this may strain the incision or cause bleeding.

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A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is B

Explanation

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