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 C
Explanation
A. Intermittent abdominal pain: While abdominal pain may occur, it is not specifically related to total parenteral nutrition (TPN) and burn care.
B. Decreased calcium levels: Decreased calcium levels are not the primary concern with TPN. Calcium levels should be monitored, but other issues are more directly related to TPN.
C. Increased serum glucose levels: This is correct as TPN often contains high levels of glucose, which can lead to hyperglycemia. Monitoring serum glucose levels is crucial in managing TPN to avoid complications.
D. Absent bowel sounds: Bowel sounds are not directly affected by TPN. However, monitoring for gastrointestinal function is important in the overall assessment of the client.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
Explanation
1. Bumetanide 1 mg IV stat: The client’s vital signs show hypotension (blood pressure 88/54 mm Hg) and tachycardia (heart rate 104/min). The skin is cool and moist, and capillary refill is delayed, suggesting possible fluid overload or heart failure. Bumetanide is a potent diuretic used to address fluid overload and reduce the heart's workload.
2. Packed red blood cells: The client’s urine output is low (110 mL over 6 hours), which, combined with signs of hypotension and tachycardia, may indicate significant blood loss or anemia. Administering packed red blood cells can help correct anemia and improve blood volume.
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