The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?
Loosen all of the connections on the vest to assess the skin
Ask about the client's ability to perform range of motion to legs
Ask how the client is able to reposition self in bed
Assess the pin sites
The Correct Answer is D
Choice A Rationale: Loosening all of the connections on the vest to assess the skin is not the first priority and may compromise the stability of the halo brace.
Choice B Rationale: Asking about the client's ability to perform range of motion to legs is important but may not be the first priority.
Choice C Rationale: Asking how the client is able to reposition self in bed is important but may not be the first priority.
Choice D Rationale: Assessing the pin sites is the first priority in caring for a client with a halo brace, as complications related to pin site infections or issues can have significant consequences. Pin site care and assessment are crucial to prevent infections and complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Rationale: Measuring the calves for symmetry is not directly related to preventing complications after repositioning.
Choice B Rationale: Palpating the bladder is important for assessing urinary retention but is not the immediate action to prevent complications after repositioning.
Choice C Rationale: Placing a pillow between the knees and ankles is the correct action to prevent complications such as pressure ulcers and skin breakdown when a client is in a side-lying position.
Choice D Rationale: Checking the gag reflex is unrelated to repositioning and preventing complications.
Correct Answer is B
Explanation
Choice A Rationale: Keeping the diaphragm in place for at least 4 hours after intercourse is a recommendation, but it does not address the specific concern of the client wanting to continue using her diaphragm postpartum.
Choice B Rationale: Having the client's provider refit her for a new diaphragm is the appropriate instruction after childbirth. The size and shape of the cervix can change postpartum, affecting the fit of the diaphragm.
Choice C Rationale: Using an oil-based vaginal lubricant can damage the diaphragm and is not recommended.
Choice D Rationale: Storing the diaphragm in sterile water after each use is not a standard practice. Proper cleaning and storage in a dry, cool place are recommended.
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.