A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement?

Log roll the client and place adult disposable briefs beneath the client.

Maintain traction while the client uses a urinal.

Release the traction so the client can use a bedpan.

Insert an indwelling urinary catheter preoperatively.

Answer and Explanation

The Correct Answer is B

Choice A reason: Log rolling the client and placing adult disposable briefs beneath the client is not a correct intervention, as it can cause displacement or misalignment of the fracture, which can lead to complications, such as delayed healing, nerve damage, or infection. Log rolling is a technique that involves moving the client as a unit, without twisting or bending the spine. Adult disposable briefs are absorbent pads that can be worn to manage urinary incontinence.

Choice B reason: Maintaining traction while the client uses a urinal is the correct intervention, as it can prevent the disruption of the fracture stabilization and allow the client to void comfortably and safely. Traction is a force that is applied to the fractured bone to reduce, align, and immobilize it. A urinal is a container that can be used to collect urine from the client, without requiring the client to get out of bed or change position.

Choice C reason: Releasing the traction so the client can use a bedpan is not a correct intervention, as it can compromise the fracture reduction and alignment, and cause pain and discomfort to the client. A bedpan is a shallow vessel that can be used to collect urine or feces from the client, by placing it under the client's buttocks. Releasing the traction can also increase the risk of bleeding, swelling, or infection.

Choice D reason: Inserting an indwelling urinary catheter preoperatively is not a necessary intervention, unless the client has urinary retention, obstruction, or infection. An indwelling urinary catheter is a tube that is inserted into the bladder through the urethra, and attached to a drainage bag. An indwelling urinary catheter can pose risks of trauma, infection, or bladder spasms, and should be avoided unless indicated.

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Correct Answer is A

Explanation

Choice A reason: Isolating the client from other clients, family, and healthcare workers not wearing proper PPE is the most important action that the nurse should take, because it can prevent the transmission of COVID-19, which is a highly contagious respiratory disease caused by a novel coronavirus. The client has symptoms that are consistent with COVID-19, such as conjunctivitis, loss of taste and smell, and recent travel history, and the nasal swab test can confirm the diagnosis. The nurse should follow the infection control precautions, such as wearing a mask, gloves, gown, and eye protection, and place the client in a private room with negative pressure ventilation, if available.

Choice B reason: Reporting the COVID-19 result to the local health department according to CDC guidelines is an important action that the nurse should take, but it is not the most important one. Reporting the COVID-19 result can help the public health authorities to monitor the epidemiology, track the contacts, and implement the interventions to control the outbreak. However, reporting the result can only be done after the test is completed and confirmed, which may take some time. The nurse should prioritize the immediate isolation of the client to prevent the spread of the virus.

Choice C reason: Teaching the client to wear a mask, hand wash, and social distance to prevent spreading the virus is an important action that the nurse should take, but it is not the most important one. Teaching the client to wear a mask, hand wash, and social distance can help the client to protect themselves and others from COVID-19, which can be transmitted through respiratory droplets, contact, and aerosols. However, teaching the client these measures can only be effective if the client follows them and adheres to the isolation guidelines. The nurse should first isolate the client and then provide the education.

Choice D reason: Explaining to the client to inform others that they may have been potentially exposed in the last 14 days is an important action that the nurse should take, but it is not the most important one. Explaining to the client to inform others that they may have been potentially exposed in the last 14 days can help the client to notify their close contacts, such as family, friends, co-workers, and travel companions, who may have been at risk of COVID-19 infection. However, explaining to the client this information can only be useful if the client cooperates and remembers their contacts. The nurse should first isolate the client and then assist the client with the contact tracing.

A. Corticosteroid cream was applied to eczema. B. A grandson and his new dog recently visited. C. An old friend with eczema came for a visit. D. Recently received an influenza immunization.

Correct Answer is B

Explanation

Choice A reason: Corticosteroid cream was applied to eczema is not a useful information in determining the possible cause of the symptoms, because it is a treatment that can reduce the inflammation and itching of eczema, not a trigger that can worsen it. Corticosteroid cream should be used as prescribed by the doctor, and the nurse should instruct the client on how to apply it correctly and safely.

Choice B reason: A grandson and his new dog recently visited is a useful information in determining the possible cause of the symptoms, because it can indicate that the client was exposed to an allergen or an irritant that can trigger an eczema flare-up. Some people with eczema may have allergic reactions to animal dander, saliva, or fur, which can cause skin inflammation, redness, and itching. The nurse should ask the client about their history of allergies and their contact with the dog, and advise them to avoid or minimize exposure to potential allergens.

Choice C reason: An old friend with eczema came for a visit is not a useful information in determining the possible cause of the symptoms, because eczema is not a contagious condition that can be transmitted from person to person. Eczema is a chronic skin disorder that causes dry, itchy, and inflamed skin, and it is influenced by genetic, environmental, and immune factors. The nurse should reassure the client that eczema is not infectious and that they can maintain social relationships with other people with eczema.

Choice D reason: Recently received an influenza immunization is not a useful information in determining the possible cause of the symptoms, because there is no evidence that influenza immunization can cause or worsen eczema. Influenza immunization is a preventive measure that can protect the client from getting the flu, which can be a serious and sometimes fatal illness, especially for people with chronic conditions, such as eczema. The nurse should encourage the client to get vaccinated for influenza and other diseases, as recommended by the doctor.

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A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

Correct Answer is B

Explanation

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