A nurse is caring for a client who has an upper cervical spinal cord injury and a halo device. Which of the following actions should the nurse take?

Ensure one finger can be inserted between the vest and client's skin.

Use the halo device to turn the client in bed.

Use a pen to itch under the vest

Tighten halo pins when loose.

Answer and Explanation

The Correct Answer is A

A. Ensure one finger can be inserted between the vest and client's skin: Allowing one finger’s space prevents skin breakdown while maintaining proper immobilization. This ensures the vest is snug enough to stabilize the cervical spine but not so tight that it causes pressure ulcers or discomfort.

B. Use the halo device to turn the client in bed: The halo device is rigid and should never be used as a lever to move the client, as this can cause cervical spine injury. Turning and repositioning should be done by supporting the head, neck, and torso manually, not by pulling on the device.

C. Use a pen to itch under the vest: Inserting objects under the vest can damage the skin and increase the risk of infection or pressure injuries. Clients should be taught to relieve itching by gentle tapping or using approved tools outside the vest.

D. Tighten halo pins when loose: Halo pins should only be adjusted by a healthcare provider. Tightening pins independently can cause skull fractures, nerve injury, or increased pain, making this action unsafe for nursing practice.

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Correct Answer is A

Explanation

A. Notify the fire department that oxygen is in use in the home.: Informing the local fire department ensures they are aware of the increased fire risk and can respond appropriately in case of an emergency. Home oxygen increases combustion potential, and early notification enhances overall household safety planning.

B. Increase the oxygen flow rate by 1 L if the client experiences dyspnea.: Changing oxygen flow rates without a prescription is unsafe because it can lead to CO₂ retention in some clients or inadequate oxygenation in others. Any adjustment to oxygen therapy must be made only by the provider to avoid complications.

C. Store oxygen tanks on their side when not in use.: Oxygen tanks should always be stored upright and secured to prevent rolling or falling, which could cause tank rupture or high-pressure release.

D. Replace the cotton blankets with wool and synthetic blankets.: Wool and synthetic materials can generate static electricity, which poses an ignition risk around oxygen. Cotton blankets are the safer option because they reduce friction and minimize static buildup.

A. "I will take my insulin 30 minutes before exercise." B. "I will limit my fluid intake to 1 liter daily." C. "I will eat a low-residue diet.” D. "I will use a mirror to inspect my feet daily,"

Correct Answer is D

Explanation

A. "I will take my insulin 30 minutes before exercise.": Administering insulin immediately before exercise increases the risk of hypoglycemia. Timing of insulin should be coordinated with meals and activity, and clients should monitor blood glucose closely before and after exercise.

B. "I will limit my fluid intake to 1 liter daily.": Restricting fluids is not recommended for clients with diabetes, as adequate hydration helps prevent hyperglycemia and supports kidney function. Limiting fluids could increase the risk of dehydration and complicate blood glucose control.

C. "I will eat a low-residue diet.": A low-residue diet is typically used for gastrointestinal disorders, not diabetes management. Clients with diabetes benefit from a balanced diet that includes fiber to help regulate blood glucose and promote overall health.

D. "I will use a mirror to inspect my feet daily.": Daily foot inspection is an important self-care practice for clients with diabetes to identify early signs of injury, infection, or neuropathy. Using a mirror helps the client see areas that are difficult to view, supporting prevention of complications such as ulcers.

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A nurse is caring for a client who has an upper cervical spinal cord injury and a halo device. Which of the following actions should the nurse take?

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