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.

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

Explanation

A. Plain, air-popped popcorn is a low-calorie, low-sodium snack that is suitable for clients with heart failure.
B. Cheddar cheese cubes are high in fat and sodium, which is not ideal for heart failure management.

C. Lightly salted potato chips still contain significant sodium, which should be limited in heart failure diets.
D. Natural whole almonds are a good source of healthy fats and protein, making them a suitable option.
E. Canned fruit in heavy syrup contains added sugars and unnecessary calories, which should be avoided.

A. Oxygen saturation 98% on room air B. Urine output 20 mL in the last hour C. Basilar crackles D. Heart rate 72 beats/minute E. Respiratory rate 26 breaths/minute F. Blood pressure 126/76 mm Hg G. Electrocardiogram Tall T wave and widened QRS complex H. Temperature 98.9° F (37.1° C) orally

Correct Answer is ["A","D","E","F","H"]

Explanation

A. Oxygen saturation of 98% on room air indicates that the client is maintaining adequate oxygenation without the need for supplemental oxygen.
B. A urine output of 20 ml within the last one hour is insufficient and could indicate an acute kidney injury.
C. Presence of crackles indicates ongoing pulmonary involvement, which does not suggest stabilization.
D. A heart rate within the normal range for a 7-year-old child (70-120 beats/minute), showing improvement from the previously irregular and elevated rate.
E. Respiratory rate of 26 breaths/minute is now within the normal range for a child (20-30 breaths/minute), indicating improved respiratory function.
F. A blood pressure of 126/76 mm Hg is within the normal range for a child.

G. Tall T wave and widened QRS complex suggest hyperkalemia, which is a serious condition and does not indicate stabilization.
H. An oral temperature of 37.1 C Indicates that the fever has resolved, suggesting that the infection or inflammatory response is under control.

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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

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