A nurse is caring for a client who is brought into the emergency department immediately following a snake bite to his forearm. The client suspects the snake to be venomous. Which of the following interventions should the nurse take?

A. Pulse rate 108 bpm and temperature 99.2F: A pulse rate of 108 bpm is elevated, but it is within the normal compensatory range for a burn injury. A temperature of 99.2°F is slightly elevated, which may be expected after a burn injury due to stress or inflammation.

B. Resp rate 18 and pulse rate 78 bpm: A pulse rate of 78 bpm is normal, and a respiratory rate of 18 breaths per minute is within the normal range. These findings suggest that the client's fluid status is stable and does not indicate signs of inadequate fluid volume.

C. B/P 109/65 and pulse rate 90 bpm: A blood pressure of 109/65 mm Hg is within normal limits, and a pulse rate of 90 bpm is slightly elevated but within a normal compensatory range. These do not indicate significant fluid deficit at this time.

D. Pulse rate 138 bpm and urine output 22mL/hr: A pulse rate of 138 bpm is high and indicates tachycardia, which is a common compensatory mechanism due to inadequate fluid volume. The urine output of 22 mL/hr is below the expected output of 30 mL/hr, indicating poor renal perfusion and inadequate fluid status.

A. "The purpose of this device is to allow for neck movement during the healing process": The purpose of the halo fixation device is to immobilize the cervical spine to promote healing and prevent further injury. It restricts neck movement to stabilize the spine.

B. "Apply talcum powder under the vest to limit friction": Applying talcum powder under the vest is not recommended as it can cause skin irritation and interfere with the fit of the device. It is better to keep the area clean and dry to prevent skin breakdown.

C. "Turn the screws on the device once each day": The screws on a halo device should never be turned by the family or the patient. Adjusting the screws is a medical procedure that should only be done by a healthcare provider to ensure proper alignment and prevent further injury.

D. "The purpose of this device is to immobilize the cervical spine": The primary function of the halo fixation device is to immobilize the cervical spine following a spinal cord injury, allowing the vertebrae to heal properly while minimizing the risk of further damage.