106 A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

Assess the pin sites for signs of infection.

Administer pain medication at designated intervals around the clock.

Assess the pulses proximal to the fracture site.

Remove traction every shift and provide skin care.

Answer and Explanation

The Correct Answer is A

A.   Assessing the pin sites for signs of infection is essential in clients with skeletal traction to detect any early signs of infection, such as redness, swelling, warmth, or purulent drainage. Prompt identification and management of pin site infections can prevent complications.
B.   Administering pain medication at designated intervals around the clock helps to ensure adequate pain control and comfort for the client. However, this intervention alone does not specifically address the care needs related to skeletal traction.
C.   Assessing the pulses proximal to the fracture site is important for monitoring circulation and detecting any signs of impaired perfusion. However, this assessment is not directly related to the care of skeletal traction itself.
D.   Removing traction every shift is not indicated unless there is a specific reason to do so as ordered by the healthcare provider. Continuous traction is often necessary for proper alignment and stabilization of the fracture. Additionally, providing skin care is important to prevent skin breakdown around the traction device, but removing traction every shift is not part of routine care.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. While monitoring urinary output is important, it is not the most critical assessment in this context.
B. Monitoring serum electrolytes is crucial because the large amount of fecal liquid output from the ileostomy can lead to significant electrolyte imbalances.
C. Peristomal skin integrity is important but is secondary to the immediate risk of electrolyte imbalances.
D. Skin turgor is important for assessing hydration status, but monitoring electrolytes is more directly related to the immediate postoperative care.

A. Bends from the waist to pick trash off the floor. B. Leans forward to pull a pan from a high shelf. C. Locks knees while preparing food on the counter. D. Widens stance while working near the sink. E. Brings a heavy can close to body before lifting.

Correct Answer is ["D","E"]

Explanation

A. Bending from the waist to pick up trash can cause imbalance and strain; it is safer to bend at the knees.

B. Leaning forward to pull a pan from a high shelf can lead to loss of balance; using a step stool is safer.
C. Locking the knees can lead to loss of balance and is not a recommended posture.

D. Widening the stance provides a stable base and helps maintain balance while working.
E. Bringing a heavy can close to the body before lifting uses proper body mechanics, reducing the risk of strain and promoting balance.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

106 A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most

Correct Answer is B

Explanation

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

Correct Answer is ["D","E"]

Explanation

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next?

Patient Data Exhibits The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

Patient's data Exhibits The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs. Which assessment findings require follow up by the nurse? Select all that apply.

When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement? Reference Range lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]

Exhibits What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.