The new graduate nurse provides care for a client with a halo external fixation device. Which actions by the new nurse are appropriate? Select all that apply.

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11ecbb05_ca20_0784_b433_a197f8456681_MD0009_00 A halo external fixation device stabilizes a cervical or high thoracic fracture when there is insignificant damage to the ligaments or spinal cord. Sensory and muscle function should be monitored to determine any new deficits, and pin sites should be regularly assessed for loose pins or infection. Care for the client with a halo device includes: Cleaning pin sites with sterile solution (eg, chlorhexidine, water) to prevent infection (Option A) Keeping the vest liner clean and dry (eg, changing weekly or when soiled, using a cool blow-dryer to dry) to protect the skin (Option E) Placing foam inserts under pressure points to prevent pressure injury Placing a small pillow under the client's head when supine to reduce pressure on the device (Option D) Keeping the correct-sized wrench available at all times in case of emergency (Option B) Only the health care provider can adjust the pins. (Option C) The nurse should avoid grabbing the device frame when moving or positioning the client, as this may cause the screws to loosen or alter device alignment. Educational objective: A halo external fixation device stabilizes a cervical or high thoracic fracture. The nurse should clean the pin sites with sterile solution to prevent infection, reduce pressure on the halo device (eg, pillow under the head), keep the vest clean and dry, and avoid holding the device frame while moving the client. Pins can be adjusted only by the health care provider.

The New Graduate Nurse Provides Care for a Client with a Halo