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

A. This position may help alleviate dyspnea by promoting better lung expansion. However, it does not address the underlying issue of fluid overload or the need for urgent action. While helpful for comfort, this action alone is insufficient.
B. Switching the IV fluid to lactated Ringer's solution does not address the issue of fluid overload and is likely to worsen the situation.
C. Slowing the infusion can help mitigate further fluid overload, and contacting the provider is crucial for further evaluation and intervention. This option prioritizes the client’s safety and addresses the symptoms being experienced.
D. Corticosteroids are not typically used to address dyspnea and hypertension associated with IV fluid administration.

A. Increase the room temperature. B. Cleanse the client's wounds. C. Administer analgesic medication. D. Start an IV with a large-bore needle.

Correct Answer is D

Explanation

D. Start an IV with a large-bore needle. Establishing intravenous access is crucial for fluid resuscitation and administering medications. It allows for timely administration of fluids and other necessary treatments to stabilize the client’s condition.
A. Increasing the room temperature is not a priority intervention for a client with a burn injury, especially immediately after securing the airway.
B. While wound care is essential in the management of burn injuries, it is not the first intervention to prioritize after securing the airway.
C. Burn injuries can be extremely painful, and providing analgesic medication is important but not a priority intervention

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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