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. Changed mental status: This is a common indicator of a bladder infection in older adults, who may present with confusion or altered mental status instead of classic symptoms like dysuria or frequency.
B. WBC count 9,000/mm³ (5000 to 10,000/mm³): This WBC count is within the normal range and does not specifically indicate a bladder infection.
C. Diminished reflexes: This is not a typical indicator of a bladder infection and may suggest other neurological issues.
D. Temperature 37.3° C (99.1° F): This temperature is within the normal range and does not suggest an infection unless elevated or accompanied by other symptoms.
Correct Answer is C
Explanation
A. Elevate the head of the bed 45° before starting the CPM device: This is incorrect as elevating the head of the bed is not a necessary preparation for using the CPM device. The device should be used according to the specific postoperative guidelines.
B. Ensure the frame joint is in a flexed position before placing the leg onto the device: This is incorrect because the frame joint should generally be in an extended position to properly align the leg for movement through the device's range of motion.
C. Ensure the knee joint is positioned over the CPM device frame joint: This is correct because proper alignment of the knee joint with the CPM device's frame joint is crucial to ensure that the device functions correctly and promotes effective range-of-motion exercises.
D. Instruct the client to increase the degree of flexion as tolerated: This is incorrect because the degree of flexion should be adjusted according to the prescribed protocol by the healthcare provider and should not be self-adjusted by the client.
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