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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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 B
Explanation
B. Seizures can result in sudden and uncontrollable movements, which may increase the risk of injury if the client strikes against the side rails of the bed during a seizure episode. Padding the upper two side rails helps minimize the risk of injury by providing a softer surface.
A. Maintaining peripheral IV access ensures that these medications can be administered promptly. However, other routes such as rectal can also be used therefore not a priority
C. Assisting personnel should not be trained in the proper application of restraints as it is not within the scope of their practice.
D. Introduction of objects during a seizure is not recommended as it increases the risk of injury.
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