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 A
Explanation
A. This is the first step to control bleeding and prevent further blood loss.
B. Monitoring the distal pulse is important, but controlling bleeding takes precedence.
C. Vital signs can wait momentarily until the bleeding is under control.
D. Reinforcing the dressing may be necessary, but controlling bleeding is the immediate priority.
Correct Answer is D
Explanation
A) Neck vein distention is not typically associated with acetylsalicylic acid poisoning.
B) Jaundice is not typically associated with acetylsalicylic acid poisoning.
C) Polyuria is not typically associated with acetylsalicylic acid poisoning.
D) Hyperpyrexia, or extremely high fever, is a common symptom of severe acetylsalicylic acid poisoning due to its effects on the central nervous system and metabolism.
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