Difficulty: Medium
Average Score: 83%
Simulated
A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?
Correct answer
B
Rationale
Correct Answer: B - Reposition the client using a turning sheet.
Rationale: Repositioning using a turning sheet helps prevent complications such as pressure ulcers and nerve damage. The halo vest immobilizes the cervical spine, making it crucial to use proper techniques to move the client safely.
Incorrect Choices:
A: Encouraging flexion and extension of the neck is contraindicated as it can disrupt spinal alignment and lead to further injury.
C: Assessing the pin sites for infection every other day is important, but not the immediate action needed for client safety and comfort.
D: Tightening the screws on the halo device without proper instruction can lead to complications, and it is not the nurse's role to adjust the device without specific orders from the healthcare provider.
Rationale: Repositioning using a turning sheet helps prevent complications such as pressure ulcers and nerve damage. The halo vest immobilizes the cervical spine, making it crucial to use proper techniques to move the client safely.
Incorrect Choices:
A: Encouraging flexion and extension of the neck is contraindicated as it can disrupt spinal alignment and lead to further injury.
C: Assessing the pin sites for infection every other day is important, but not the immediate action needed for client safety and comfort.
D: Tightening the screws on the halo device without proper instruction can lead to complications, and it is not the nurse's role to adjust the device without specific orders from the healthcare provider.