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 D
Explanation
Choice A rationale
The human papillomavirus (HPV) vaccine is not typically given at 12 months of age. It is usually administered to adolescents.
Choice B rationale
The inactivated polio virus vaccine is not typically given at 12 months of age. It is usually administered earlier in infancy.
Choice C rationale
The hepatitis B vaccine is not typically given at 12 months of age. It is usually administered shortly after birth and in the first few months of life.
Choice D rationale
The varicella vaccine, which protects against chickenpox, is typically given at 12 months of age.
Correct Answer is A
Explanation
Choice A rationale
A creatinine level of 1.4 mg/dL is higher than the normal range and could indicate kidney damage, which is a known side effect of gentamicin. Therefore, the nurse should notify the healthcare provider.
Choice B rationale
A creatinine level of 0.3 mg/dL is within the normal range, so it would not typically be a cause for concern.
Choice C rationale
A BUN level of 12 is within the normal range, so it would not typically be a cause for concern.
Choice D rationale
A BUN level of 6 is within the normal range, so it would not typically be a cause for concern.
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