A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?
Move the client up and down in bed by holding onto the halo traction device.
Ensure that there is space for one finger to fit between the vest and the client's skin.
Apply medicated powder under the vest to reduce itching.
Loosen or tighten the screws on the device as needed for the client's comfort.
The Correct Answer is B
B. Ensuring that there is space for one finger to fit between the vest and the client's skin helps prevent skin breakdown and pressure injuries. The halo vest should fit snugly but not too tight to allow for proper circulation and comfort.
A. Moving the client by holding onto the halo traction device can disrupt the device's stability and potentially cause harm to the client.
C. Applying medicated powder under the vest can introduce foreign substances to the skin and may increase the risk of skin irritation or infection.
D. This should only be performed under the guidance of a healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. After breaking the top of the ampule to access the medication, the nurse should dispose of the top portion safely in a sharps container to prevent accidental needlestick injuries and ensure proper disposal of sharps waste.
B. Expelling air into the ampule can increase the pressure inside, potentially causing medication to spill out or splatter when the ampule is opened.
C. To open an ampule safely, the nurse should use an ampule opener around the neck of the ampule to protect their hands from potential injury. By breaking off the top with both hands, the nurse can minimize the risk of accidental cuts or lacerations.
D. Withdrawing medication from an ampule requires the use of a needle and syringe. However, some medications may be supplied in ampules with pre-attached needleless systems for withdrawal.
Correct Answer is D
Explanation
Thawed FFP should be administered promptly. It can be stored at 1 to 6 degrees Celsius for up to 24 hours if not used immediately. However, it is best to administer it as soon as possible after thawing.
A. FFP should be administered through a larger-bore intravenous catheter (typically 18-20 gauge) to prevent clotting or clogging of the line.
B. The recommended infusion time for FFP is approximately 30 minutes to 1 hour. Rapid infusion helps maintain clotting factor activity.
C. FFP is specifically used to manage bleeding due to coagulopathy. If the client is actively bleeding, timely FFP administration is crucial.
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