A nurse is caring for a client who is postoperative 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
Assess the pin sites for injection once every other day
Reposition the client using a turning sheet
Tighten the screw on the halo device once-quarter turn every 48 hr. .
The Correct Answer is C
Choice A rationale
Encouraging flexion and extension of the neck in a client with a halo vest for cervical vertebral fracture is not recommended. The purpose of the halo vest is to immobilize the neck to allow healing.
Choice B rationale
Assessing the pin sites for infection once every other day is not typically recommended. More frequent assessments are usually necessary to promptly identify any signs of infection.
Choice C rationale
Repositioning the client using a turning sheet is the correct action. This method of repositioning can help to prevent skin breakdown and pressure ulcers, which are potential complications for clients who are immobilized.
Choice D rationale
Tightening the screw on the halo device once-quarter turn every 48 hours is not typically recommended. Adjustments to the halo device should be made by a healthcare professional as needed based on the client’s condition and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Encouraging flexion and extension of the neck in a client with a halo vest for cervical vertebral fracture is not recommended. The purpose of the halo vest is to immobilize the neck to allow healing.
Choice B rationale
Assessing the pin sites for infection once every other day is not typically recommended. More frequent assessments are usually necessary to promptly identify any signs of infection.
Choice C rationale
Repositioning the client using a turning sheet is the correct action. This method of repositioning can help to prevent skin breakdown and pressure ulcers, which are potential complications for clients who are immobilized.
Choice D rationale
Tightening the screw on the halo device once-quarter turn every 48 hours is not typically recommended. Adjustments to the halo device should be made by a healthcare professional as needed based on the client’s condition and comfort.
Correct Answer is D
Explanation
Choice A rationale
Polyuria, or excessive urination, is not a typical symptom of acute acetylsalicylic acid poisoning.
Choice B rationale
Neck vein distension is not a typical symptom of acute acetylsalicylic acid poisoning.
Choice C rationale
Jaundice, or yellowing of the skin and eyes, is not a typical symptom of acute acetylsalicylic acid poisoning.
Choice D rationale
Hyperpyrexia, or extremely high fever, can be a symptom of severe acute acetylsalicylic acid poisoning.
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