A nurse is contributing to the care plan for a client who has a halo vest following a cervical fracture 8 hours ago. Which intervention should the nurse recommend for inclusion in the plan?
Loosen the screws while cleaning the pin sites.
Turn the client every 4 hours.
Change the sheepskin lining under the device weekly.
Reposition the client in bed using the halo ring.
The Correct Answer is C
Choice A rationale
Loosening the screws while cleaning the pin sites is not recommended. The screws are tightened to a specific pressure to ensure the halo vest is secure and provides the necessary immobilization.
Choice B rationale
The nurse should also provide education regarding changing positions at least every 2 hours to reduce pressure injuries.
Choice C rationale
Halo-vests are managed and monitored during spinal outpatient clinics and can be removed during this clinic appointment.
Choice D rationale
The halo ring should never be used to lift or reposition the client because it is directly attached to the skull. Pulling on the ring could cause serious injury or dislocation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C rationale
Placing the client in Fowler's position (semi-upright position) facilitates optimal chest expansion and improves ventilation by allowing the diaphragm to move more effectively and reducing the pressure on the lungs from abdominal contents. This position helps in maximizing oxygenation and reducing respiratory distress. The other positions—supine, prone, and Trendelenburg—do not offer the same level of chest expansion and can exacerbate breathing difficulties.
The correct answer is to place the client in a position that allows for maximum chest expansion and oxygenation. This is often the upright or Fowler’s position.
Correct Answer is A
Explanation
Choice A rationale
If 500 mL of fluid is removed during thoracentesis, the nurse should notify the provider. Removing large volumes of fluid can cause re-expansion pulmonary edema.
Choice B rationale
A clear chest x-ray is an expected finding after thoracentesis.
Choice C rationale
PCO2 is a measure of carbon dioxide levels in the blood. It is not directly related to thoracentesis.
Choice D rationale
Hematocrit is a measure of the proportion of red blood cells in the blood. It is not directly related to thoracentesis.
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