A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)
a. Tape a halo wrench to the client's vest.
b. Assess the pin sites for signs of infection.
c. Loosen the pins when sleeping.
d. Decrease the client's oral fluid intake.
e. Assess the chest and back for skin breakdown.
ANS: A, B, E
A special halo wrench should be taped to the client's vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest.
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