a nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine which of the fol

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

A. Inspect the pin site every 4 hours
B. Monitor the client's skin under the halo vest
C. Ensure two personnel hold the halo device when repositioning the client
D. Apply powder to the client's skin under the vest to decrease itching

Correct answer: B

Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.

2. What are the early symptoms of compartment syndrome?

A. Unrelieved pain, pallor, and pulselessness
B. Localized redness and swelling
C. Fever and swelling
D. Numbness and tingling

Correct answer: A

Rationale: The correct answer is A: 'Unrelieved pain, pallor, and pulselessness.' Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to reduced blood flow and potential tissue damage. Early symptoms include unrelieved pain (out of proportion to the injury), pallor (pale skin color), and pulselessness (decreased or absent pulses). Choices B, C, and D are incorrect as they do not represent the classic early symptoms of compartment syndrome.

3. A patient reports abdominal cramping after enema administration. What is the appropriate action?

A. Lower the height of the solution container
B. Stop the procedure and remove tubing
C. Increase the flow of enema solution
D. Continue the enema at a slower rate

Correct answer: A

Rationale: Lowering the height of the enema solution container is the appropriate action when a patient reports abdominal cramping after enema administration. This helps reduce the flow rate of the solution, potentially alleviating the cramping. Stopping the procedure and removing tubing (Choice B) would be too abrupt and may not address the issue. Increasing the flow of enema solution (Choice C) could exacerbate the cramping by adding more pressure. Continuing the enema at a slower rate (Choice D) might not provide immediate relief compared to lowering the height of the solution container.

4. What is the preferred electrical intervention for a patient with ventricular tachycardia with a pulse?

A. Synchronized cardioversion
B. Defibrillation
C. Pacing
D. Medication administration

Correct answer: A

Rationale: The correct answer is A: Synchronized cardioversion. In ventricular tachycardia with a pulse, synchronized cardioversion is the preferred electrical intervention. Synchronized cardioversion is used to treat tachyarrhythmias where there is a pulse present. Defibrillation (choice B) is used in emergencies for pulseless ventricular tachycardia or ventricular fibrillation. Pacing (choice C) is more suitable for bradycardias or certain conduction abnormalities. Medication administration (choice D) may be used in stable cases or as an adjunct to other treatments, but synchronized cardioversion is the primary intervention for ventricular tachycardia with a pulse.

5. What is the purpose of an escharotomy?

A. To relieve pressure and improve circulation in burn injuries
B. To reduce pain in the affected area
C. To remove necrotic tissue from a wound
D. To prevent infection from spreading

Correct answer: A

Rationale: An escharotomy is performed to relieve pressure and improve circulation in areas affected by deep burns. This procedure helps prevent complications such as compartment syndrome by releasing the constricting eschar. Choice B is incorrect because while pain relief may be a secondary outcome of the procedure, the primary purpose is to address pressure and circulation issues. Choice C is incorrect as an escharotomy specifically focuses on releasing pressure, not removing necrotic tissue. Choice D is incorrect as the primary goal of an escharotomy is not to prevent infection but rather to address the immediate issues related to deep burn injuries.