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.
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Related Questions
Correct Answer is C
Explanation
Correct Answer: C Rationale:
A. Vomiting may occur with various gastrointestinal conditions but is not a specific finding associated with necrotizing enterocolitis. Bloody stools are more characteristic of this condition.
B. Hypertension is not typically associated with necrotizing enterocolitis. Instead, infants may present with hypotension due to sepsis or shock.
C. A rounded abdomen is a common finding in necrotizing enterocolitis due to abdominal distention from gas and fluid accumulation in the intestines.
D. Tachypnea may occur as a result of sepsis or respiratory distress but is not specific to necrotizing enterocolitis.
Correct Answer is A
Explanation
A. A child with HIV is at increased risk of developing tuberculosis and should be screened annually.
B. This is incorrect because the risk of transmission does not depend on the duration of zidovudine therapy, but on the viral load and the exposure to body fluids.
C. Doubling medications is not a standard practice in HIV management and may lead to medication errors or adverse effects.
D. Childhood immunizations are important for children with HIV, but they may need to be adjusted based on the child's immune status and treatment regimen, not just during remission.
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