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 B

Explanation

A. Collecting the blood sample from a reddened and engorged fingertip may lead to inaccurate glucose readings and can cause discomfort to the client. Selecting another finger is a more appropriate action.

B. Selecting another finger ensures an accurate blood sample and minimizes discomfort to the client. It allows for a fresh puncture site that is not engorged, improving the accuracy of the glucose reading.

C. Applying pressure to the site may temporarily reduce engorgement but may not be sufficient to obtain an accurate blood sample. Selecting another finger is a more appropriate action.

D. Assessing radial pulse volume is not necessary in this situation, as the client's fingertip appearance does not indicate compromise of peripheral circulation.

A. Ensure oral suction is available. B. Provide frequent mouth care. C. Keep the room at a comfortable temperature. D. Maintain the client in a semi-Fowler's position.

Correct Answer is A

Explanation

A. Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.

B. Providing frequent mouth care is important for oral hygiene but may not be as critical as ensuring a patent airway during seizures.

C. Keeping the room at a comfortable temperature is important for overall comfort but is not the most essential intervention during seizure activity.

D. Maintaining the client in a semi-Fowler's position may help with ventilation and drainage but is not as crucial as ensuring airway patency.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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