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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Airway obstruction is not a common complication of a femoral head fracture or skin traction.

Choice B rationale

Pneumonia can cause shortness of breath but is not the most likely complication in this scenario.

Choice C rationale

Pneumothorax is less likely in this context compared to a fat embolism.

Choice D rationale

Fat embolism is a known complication of fractures, especially long bone fractures like the femoral head. It can cause respiratory distress and dyspnea.

A. Use friction when washing the affected area. B. Use a new cosmetic pad with each limited application of makeup. C. Use an oil-based soap to wash affected areas daily. D. Express the larger comedones periodically.

Correct Answer is B

Explanation

Choice A rationale

Using friction when washing the affected area can irritate the skin and worsen acne. Gentle cleansing is recommended to avoid aggravating the condition.

Choice B rationale

Using a new cosmetic pad with each limited application of makeup helps prevent the spread of bacteria and reduces the risk of further clogging pores, which can exacerbate acne.

Choice C rationale

Using an oil-based soap can clog pores and worsen acne. Non-comedogenic, water-based cleansers are recommended for acne-prone skin.

Choice D rationale

Expressing larger comedones periodically can lead to skin damage and scarring. It is better to use appropriate acne treatments to manage comedones.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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