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.
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Related Questions
Correct Answer is B
Explanation
B. Ondansetron is a commonly used medication for preventing nausea and vomiting induced by chemotherapy. It belongs to a class of drugs called serotonin receptor antagonists, which work by blocking serotonin receptors in the brain and gastrointestinal tract, thereby reducing the sensation of nausea and the urge to vomit. Ondansetron is often administered prior to chemotherapy to help prevent these side effects.
A. Diphenhydramine works by blocking histamine receptors in the brain that trigger nausea and vomiting. However, it is not commonly used as a first-line antiemetic for chemotherapy-induced nausea and vomiting.
C. Sertraline is a selective serotonin reuptake inhibitor (SSRI) antidepressant and is not used specifically for preventing chemotherapy-induced nausea and vomiting.
D. Methylprednisolone is a corticosteroid medication that has anti-inflammatory and immunosuppressant effects.
Correct Answer is C
Explanation
C. When collecting a stool specimen from a client with Clostridium difficile infection, the nurse should wear gloves to prevent the spread of the bacteria to themselves and other patients. Proper hand hygiene should also be performed after glove removal.
A. While alcohol-based hand rubs are effective against many types of bacteria and viruses, they are not effective against Clostridium difficile spores. Handwashing with soap and water is recommended for hand hygiene in cases of Clostridium difficile infection, as it is more effective at removing spores from the hands.
B. Chlorhexidine is a disinfectant commonly used for skin antisepsis, but it is not effective against
D. Placing the client in a protective environment is not typically necessary for clients with Clostridium difficile gastroenteritis unless they are immunocompromised or have other conditions that require protective isolation.
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