A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?
Remove the vest daily to inspect the client’s skin integrity.
Check that the halo jacket is snug against the client’s skin.
Provide range of motion to the client’s neck.
Monitor the client for an elevated temperature.
The Correct Answer is D
Choice A rationale
Removing the vest daily is not recommended as it can disrupt the alignment and stability provided by the halo fixation device.
Choice B rationale
The halo jacket should be snug but not too tight to avoid pressure sores and discomfort.
Choice C rationale
Providing range of motion to the neck is contraindicated as the halo fixation device is meant to immobilize the cervical spine.
Choice D rationale
Monitoring for an elevated temperature is crucial as it can indicate an infection, which is a common complication with halo fixation devices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A mesh-like device within the catheter that springs open is characteristic of a stent, not a balloon-tipped catheter used in PTCA. Stents are often used in conjunction with angioplasty to keep the artery open after the balloon has compressed the plaque.
Choice B rationale
While catheters can be used to take pressure measurements, this is not the primary function of the balloon-tipped catheter in PTCA. The main purpose of the balloon-tipped catheter is to compress the plaque against the artery wall to improve blood flow.
Choice C rationale
The balloon-tipped catheter in PTCA is used to compress the plaque against the coronary blood vessel wall. This process, known as balloon angioplasty, helps to widen the artery and improve blood flow to the heart.
Choice D rationale
Cutting away plaque with an embedded blade is a description of atherectomy, not PTCA. Atherectomy involves a different type of catheter designed to remove plaque from the artery wall.
Correct Answer is D
Explanation
Choice A rationale
Dextrose 5% in water is not recommended for initial fluid resuscitation in burn patients because it does not provide the necessary electrolytes to address the fluid shifts and electrolyte imbalances that occur after a burn injury.
Choice B rationale
0.45% sodium chloride is a hypotonic solution and is not suitable for initial fluid resuscitation in burn patients. It can lead to cellular swelling and does not adequately replace the lost extracellular fluid.
Choice C rationale
Dextrose 5% in 0.9% sodium chloride is not the preferred choice for initial fluid resuscitation in burn patients. While it provides both glucose and electrolytes, it is not as effective as Lactated Ringers in addressing the specific needs of burn patients.
Choice D rationale
Lactated Ringers is the recommended fluid for initial resuscitation in burn patients. It is an isotonic solution that helps to restore circulating volume, correct electrolyte imbalances, and prevent hypovolemic shock.
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