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?
Tighten the screws on the halo device one-quarter turn every 48 hr.
Assess the pin sites for infection once every other day.
Encourage flexion and extension of the neck.
Reposition the client using a turning sheet.
The Correct Answer is D
- A: Tighten the screws on the halo device one-quarter turn every 48 hr.
- Rationale: This action is incorrect because the screws on a halo device should not be adjusted by the nurse. The screws are typically set and secured by a healthcare provider, and any adjustments can compromise the integrity of the device and the stability of the cervical spine.
- B: Assess the pin sites for infection once every other day.
- Rationale: While it is important to monitor the pin sites for signs of infection, doing so once every other day may not be sufficient. Pin sites should be assessed at least once per shift to ensure early detection and management of any potential infection.
- C: Encourage flexion and extension of the neck.
- Rationale: This action is contraindicated for a client with a halo vest. The purpose of the halo vest is to immobilize the cervical spine to promote healing. Encouraging neck movement could cause further injury or delay healing.
- D: Reposition the client using a turning sheet.
- Rationale: This is the correct action. Using a turning sheet helps to reposition the client safely and effectively without exerting unnecessary pressure on the cervical spine. It also aids in preventing pressure ulcers and promotes comfort for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The cream should be removed after it has been on the skin for the recommended amount of time. It is typically wiped off before the procedure.
B. The medication should applied repeatedly to provide analgesia
C. Washing the site with alcohol before applying the cream is not necessary and may cause unnecessary skin irritation.
D. Lidocaine and prilocaine cream typically require about 60 minutes to take effect.
Correct Answer is A
Explanation
A. Increased restlessness can indicate hypoxia, pain, or worsening shock, which are critical concerns in a toddler with significant burns. This finding should be reported immediately.
B. Respiratory rate of 25/min is within the normal range for a toddler (22-37 breaths per minute) and does not require immediate intervention.
C. Bowel sounds of 20/min are normal and do not indicate a complication.
D. Urinary output of 35 mL/hr is adequate for a toddler (goal: ≥1-2 mL/kg/hr, which would be ≥20-40 mL/hr for a 20 kg child) and does not require reporting.
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