The student nurse is planning care for a patient with a recent spinal cord injury. Which intervention indicates that the student nurse requires further instruction regarding appropriate care for this patient?

Question

a. Keep the halo jacket fastened unless the patient is in a supine position.
b. Monitor the bladder every 4 hours for signs of bladder distention.
c. Instruct unlicensed assistive personnel (UAP) to turn and reposition the patient every 2 hours.
d. Assess compression stockings for proper fit.

Answer 1

C
Moving or positioning the patient with neurologic injury or surgery should not be delegated to unlicensed personnel. Following proper instruction, the UAP can assist the nurse with moving or repositioning the patient. Halo jackets must be kept fastened unless the patient is in a supine po-sition in order to prevent sudden head movement. Bladder distention should be avoided to pre-vent infection or autonomic dysreflexia. Compression stockings are used to prevent deep vein thrombosis.