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 D
Explanation
A. Decreased bronchospasms: Metoprolol, a beta-blocker, does not typically decrease bronchospasms and may actually exacerbate them in susceptible individuals.
B. Increased blood glucose level: Metoprolol does not generally increase blood glucose levels. However, it can mask hypoglycemic symptoms in diabetic patients.
C. Increased blood pressure: Metoprolol is used to lower blood pressure, not increase it.
D. Decreased heart rate: This is correct as metoprolol is a beta-blocker that reduces heart rate by blocking beta-adrenergic receptors.
Correct Answer is ["10"]
Explanation
• Desired dose: 25 mg
• Available concentration: 12.5 mg/5 mL
• To find the volume to administer, we can use the formula:
• Volume to administer (mL) = Desired dose (mg) / Concentration (mg/mL)
• First, we need to find the concentration in mg/mL:
• Concentration = 12.5 mg / 5 mL = 2.5 mg/mL
• Now, we can calculate the volume:
• Volume to administer = 25 mg / 2.5 mg/mL = 10 mL
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