Nokea
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?
- A. Remove the vest daily to inspect the client’s skin integrity.
- B. Check that the halo jacket is snug against the client’s skin.
- C. Provide range of motion to the client’s neck.
- D. Monitor the client for an elevated temperature.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client for an elevated temperature. This is important because an elevated temperature could indicate infection, which is a significant concern when a client has a halo fixation device. Removing the vest daily (Choice A) is not recommended as it can compromise the stability of the device. Checking that the halo jacket is snug (Choice B) is important, but monitoring for an elevated temperature is a higher priority. Providing range of motion to the client's neck (Choice C) is contraindicated with a halo device as it can cause serious injury.
You may also like to solve these questions
A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?
- A. The ropes are in the center of the wheel grooves.
- B. The ropes are securely attached to the pins.
- C. The weights are equal on each side.
- D. The weights rest against the foot of the bed.
Correct Answer: D
Rationale: The correct answer is D because the weights in skeletal traction should not rest against the foot of the bed to ensure proper traction force. The weights need to hang freely to provide continuous traction on the affected body part. Placing the weights against the foot of the bed could lead to uneven or inadequate traction force, affecting the treatment effectiveness and potentially causing harm to the client.
Choice A is incorrect because the ropes should be in the center of the wheel grooves to maintain proper alignment and prevent slipping. Choice B is incorrect because the ropes should be securely attached to the pins to ensure stability and prevent accidental detachment. Choice C is incorrect because the weights do not need to be equal on each side; the amount of weight applied is determined by the healthcare provider based on the specific treatment plan.
A client diagnosed with diverticulitis has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet during the asymptomatic period?
- A. High in carbohydrates.
- B. High in fiber.
- C. Low in residue.
- D. Low in fat.
Correct Answer: B
Rationale: The correct answer is B: High in fiber. During the asymptomatic period of diverticulitis, a high-fiber diet helps prevent diverticula formation and reduces the risk of diverticulitis flare-ups by promoting regular bowel movements and preventing constipation. Fiber also helps maintain healthy gut flora. Choices A, C, and D are incorrect as high carbohydrates may worsen symptoms, low residue may lead to constipation, and low fat is not directly related to diverticulitis management.
The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?
- A. Weak pedal pulses.
- B. Complaints of leg discomfort.
- C. Toes are warm and demonstrate a brisk capillary refill.
- D. Drainage at the pin sites.
Correct Answer: A
Rationale: The correct answer is A: Weak pedal pulses. Buck's traction is used for immobilization and alignment of fractures, particularly femoral fractures. Weak pedal pulses indicate impaired circulation, which could lead to complications like compartment syndrome or deep vein thrombosis. Monitoring pulses is crucial in assessing the circulation to the affected limb. Choice B (Complaints of leg discomfort) is common and expected with traction but doesn't indicate a complication. Choice C (Toes are warm and demonstrate a brisk capillary refill) indicates good circulation. Choice D (Drainage at the pin sites) may indicate infection but is not a specific complication related to traction.
A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)
- A. Palpate the area behind the ankle bone.
- B. Use the pads of the fingers to feel for the pulse.
- C. Compare the pulse strength with the other leg.
- D. Assess for any swelling or tenderness.
Correct Answer: A,B,C
Rationale: The correct actions to assess the posterior tibial pulse are A, B, and C. A: Palpating the area behind the ankle bone locates the posterior tibial pulse accurately. B: Using the pads of the fingers helps to detect the pulse's strength and regularity. C: Comparing pulse strength with the other leg enables the nurse to identify any discrepancies. D: Assessing for swelling or tenderness is not directly related to locating the pulse. Therefore, choices D, E, F, and G are incorrect for assessing the posterior tibial pulse.
A client is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA) to treat coronary artery disease. What information about the balloon-tipped catheter would the nurse plan to include when providing client education concerning the procedure?
- A. A mesh-like device within the catheter will be inflated causing it to spring open.
- B. The catheter will be positioned in a coronary artery to take pressure measurements in the vessel.
- C. The catheter will be used to compress the plaque against the coronary blood vessel wall.
- D. The catheter will cut away the plaque from the coronary vessel wall using an embedded blade.
Correct Answer: C
Rationale: Correct Answer: C - The catheter will be used to compress the plaque against the coronary blood vessel wall.
Rationale: During a PTCA procedure, a balloon-tipped catheter is used to compress the plaque against the vessel wall, widening the artery lumen and improving blood flow. This process does not involve cutting away the plaque or taking pressure measurements. Option A is incorrect as the catheter does not spring open but rather compresses the plaque. Option B is incorrect as the catheter is not used for pressure measurements. Option D is incorrect as there is no embedded blade to cut away the plaque.