Ati rn pediatrics 2023 proctored exam
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?
Explanation & Rationale
A. The halo vest immobilizes the cervical spine completely. Any movement that might disturb the alignment of the spine is contraindicated. Using a turning sheet could potentially cause movement and damage the spine. B. Tightening the screws without medical direction can be harmful. The screws should be checked regularly by healthcare professionals, and adjustments made as needed. C. The entire purpose of the halo vest is to immobilize the neck. Any movement of the neck could disrupt the healing process and cause further injury. D. Pin site care is crucial to prevent infection. The nurse should assess the pin sites regularly for signs of infection, such as redness, swelling, drainage, or increased pain.
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