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.

Answer and Explanation

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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Correct Answer is C

Explanation

C. Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
A. Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
D. Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.

A. Administer the transfusion through a 25-gauge saline lock. B. Transfuse the plasma over 4 hr. C. Hold the transfusion if the client is actively bleeding. D. Administer the plasma immediately after thawing.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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