A nurse is contributing to the plan of care for a client who has a halo vest after experiencing a cervical fracture 8 hr ago. Which of the following interventions should the nurse recommend including in the plan?
Reposition the client in bed using the halo ring.
Turn the client every 4 hr.
Loosen the screws while cleansing the pin sites.
Change the sheepskin lining under the device weekly.
The Correct Answer is A
A. When caring for a client with a halo vest after a cervical fracture, it's essential to maintain spinal alignment and prevent further injury. Repositioning the client using the halo ring ensures that the cervical spine remains immobilized during movement, thereby reducing the risk of additional damage. This method provides controlled movement while preserving the integrity of the spinal column.
B. This is incorrect. While frequent turning is necessary to prevent complications such as pressure injuries, turning every 2 hours (not 4) is the standard for immobile clients.
C. Loosen the screws while cleansing the pin sites: This is incorrect as loosening the screws can compromise the stability of the halo vest. Pin site care should be done carefully without altering the tension of the screws.
D. Change the sheepskin lining under the device weekly: This is not frequent enough for proper hygiene and skin care; the lining should be checked more regularly and changed as needed to maintain skin integrity and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I should use my wrist to test the temperature of the water before bathing": This is correct as using the wrist to test water temperature helps prevent burns or injuries, which is crucial for individuals with diabetes who may have reduced sensation in their feet.
B. "I should put lotion between my toes every day to prevent dryness and cracking": This is incorrect because applying lotion between the toes can promote fungal infections. Lotion should be applied to the tops and soles of the feet, avoiding the spaces between the toes.
C. "I should apply a heating pad to my feet every night to help with circulation": This is incorrect as heating pads can cause burns due to decreased sensation. It is safer to avoid direct heat applications.
D. "I should round the corners of my toenails with a nail file to prevent ingrown nails": This is incorrect; toenails should be trimmed straight across to prevent ingrown nails rather than rounded.
Correct Answer is C
Explanation
A. Presence of gag reflex: This is normal after a bronchoscopy as the gag reflex indicates that the client is recovering from sedation.
B. Sore throat: This is a common and expected finding after a bronchoscopy due to irritation of the throat.
C. Facial edema: This is correct as facial edema may indicate an allergic reaction or complication, and it should be reported to the provider immediately.
D. Blood pressure 110/78 mm Hg: This is within the normal range and does not typically require reporting unless there are other symptoms present.
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