A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?
Encourage flexion and extension of the neck.
Reposition the client using a turning sheet.
Assess the pin sites for infection once every other day.
Tighten the screws on the halo device one-quarter turn every 48 hr.
The Correct Answer is B
A. The nurse should not encourage flexion and extension of the neck, as this could cause further injury or damage to the spinal cord.
B. The nurse should reposition the client using a turning sheet to prevent skin breakdown and maintain alignment of the spine.
C. The nurse should assess the pin sites for infection at least once a day, not every other day.
D. The nurse should not tighten the screws on the halo device, as this could cause pressure ulcers or nerve damage. Only a provider can adjust the screws on the halo device.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Administering vaccines prior to discharge may be contraindicated in a child with neutropenia due to the risk of infection from live vaccines.
B. Avoiding raw fruits and vegetables helps reduce the risk of exposure to harmful bacteria or pathogens that could lead to infection in a child with neutropenia, as their immune system is compromised.
C. Bathing the child every other day is a general hygiene practice and does not specifically address the risk of infection associated with neutropenia.
D. Obtaining the child's rectal temperature once daily is a routine assessment and does not directly address the risk of infection associated with neutropenia.
Correct Answer is B
Explanation
A) An increase in potassium levels is not an expected finding with furosemide; instead, hypokalemia is a potential side effect.
B) Furosemide is a diuretic commonly used to decrease fluid retention and edema, so a decrease in peripheral edema would indicate the medication's effectiveness.
C) A decrease in cardiac output is not a desired effect of furosemide and may indicate worsening heart failure.
D) An increase in venous pressure would suggest venous congestion, which is not an indication of effective furosemide therapy.
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