The nurse is preparing to care for a patient with a spinal fracture who has a halo device in place. The nurse plans to implement the following orders:

Soak the pin sites with alcohol pads

Remove the vest when bathing the patient

Assess the chest and back for skin breakdown

Assess pin sites frequently for signs of infection

Tape a halo wrench to the vest for emergencies

Answer and Explanation

Correct Answer : C,D,E

Choice A reason:

Soaking the pin sites with alcohol pads is not recommended as it can dry out the skin and increase the risk of infection. Pin site care typically involves using saline or other recommended solutions to clean the area gently.

Choice B reason:

Removing the vest when bathing the patient is not recommended. The vest provides stability and support for the spinal fracture, and removing it can compromise the patient's safety. Alternative methods should be used to maintain hygiene without removing the vest.

Choice C reason:

Assessing the chest and back for skin breakdown is crucial in patients with a halo device to prevent pressure ulcers and other skin issues. Regular assessment helps identify any potential problems early.

Choice D reason:

Assessing pin sites frequently for signs of infection is essential to prevent complications. Infection at the pin sites can lead to serious issues, and frequent monitoring ensures any signs of infection are caught and treated promptly.

Choice E reason:

Taping a halo wrench to the vest is important for emergencies. The wrench is necessary to quickly remove the halo device if needed in an emergency situation, such as if the patient requires resuscitation.

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Correct Answer is C

Explanation

Choice A reason:

A Glasgow Coma Scale (GCS) score that improves from 9 to 12 indicates a positive trend in the patient's neurological status. While monitoring is still required, this patient is not the highest priority.

Choice B reason:

A patient requesting pain medication for a new onset headache needs attention, but this is not as urgent as a significant decline in the Glasgow Coma Scale score, which can indicate a deterioration in neurological function.

Choice C reason:

A Glasgow Coma Scale score that drops from 10 to 8 signifies a significant decline in the patient's neurological status, indicating potential worsening of the condition. This patient requires immediate assessment and intervention to identify and address the cause of the deterioration.

Choice D reason:

A patient with a moderate brain injury who is amnesic for the event needs ongoing monitoring, but this is not as urgent as addressing a significant drop in the Glasgow Coma Scale score.

A. Administer fluids. B. Give pain medications as ordered. C. Prepare the patient for a CT scan. D. Prepare to assist with intubation.

Correct Answer is D

Explanation

Choice A reason:

Administering fluids is important for maintaining hemodynamic stability, but it is not the immediate priority for a patient with compromised respiration and low oxygen saturation.

Choice B reason:

Giving pain medications is necessary for patient comfort but is not the priority in a situation where the patient's respiratory status is severely compromised.

Choice C reason:

Preparing the patient for a CT scan can help assess internal injuries but is not the immediate priority when the patient is cyanotic and has low oxygen saturation. Immediate respiratory support is required first.

Choice D reason:

Preparing to assist with intubation is the priority action. The patient's oxygen saturation is critically low, and the chest wall is not moving normally, indicating potential respiratory failure. Intubation and mechanical ventilation are necessary to secure the airway and provide adequate oxygenation.

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The nurse is preparing to care for a patient with a spinal fracture who has a halo device in place. The nurse plans to implement the following orders:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for four patients in the neurologic intensive care unit. After receiving the hand-off report, which patient does the nurse see first?

Correct Answer is C

Explanation

A patient is brought to the emergency department after sustaining injuries in a severe car crash. The patient's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the patient is cyanotic. What action by the nurse is the priority?

Correct Answer is D

Explanation

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