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.
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.
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Related Questions
Correct Answer is {"dropdown-group-1":"A"}
Explanation
Epidural anesthesia, commonly used for pain relief during labor, works by blocking nerve impulses in the lower part of the spine, leading to a decrease in sensation and pain in that area. However, this blockade also affects the sympathetic nerves, which are responsible for regulating blood pressure. When these nerves are blocked, they can cause peripheral vasodilation, which is the widening of the blood vessels in the periphery of the body.
Peripheral vasodilation leads to a decrease in vascular resistance, which can significantly lower blood pressure. This drop in blood pressure, known as hypotension, is a common side effect of epidural anesthesia. Hypotension can reduce the blood flow to vital organs, including the placenta, which may affect fetal oxygenation if not promptly and effectively managed. This necessitates careful monitoring and management, typically involving fluid administration and sometimes the use of medications to maintain stable blood pressure during the administration of epidural anesthesia.
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"A,B"}}
Explanation
Side positioning can help with pain relief and prevent hypotension, which is beneficial for both maternal and fetal well-being. Urinary drainage (B) is typically a maternal intervention to manage the effects of epidural anesthesia on bladder function. Assisting with pushing efforts is a maternal intervention that supports the mother during the second stage of labor. Administering IV fluids is an intervention for the mother to maintain hydration and blood pressure, which indirectly benefits the fetus. Monitoring blood pressure is essential for both maternal and fetal health, as stable maternal blood pressure is critical for adequate fetal perfusion.
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