A male client who fractured his right femur from a fall at home is placed in Buck’s skin traction while awaiting surgery. When the client informs the nurse of the need to urinate, which intervention should the nurse implement?
Log roll the client and place adult disposable briefs beneath the client.
Release the traction so the client can use a bedpan.
Insert an indwelling urinary catheter preoperatively.
Maintain traction while the client uses a urinal.
The Correct Answer is D
Choice A reason: Log rolling disrupts traction alignment and risks compromising fracture stabilization.
Choice B reason: Releasing traction is contraindicated unless ordered by the provider, as it may interfere with fracture management.
Choice C reason: Indwelling catheterization is invasive and not indicated unless the client is unable to void by other means.
Choice D reason: Maintaining traction while using a urinal preserves alignment and allows the client to void without compromising orthopedic care. This is the safest and most appropriate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Wet compresses help soothe the skin and debride crusts from ruptured vesicles, providing symptomatic relief for the inflammatory skin lesions, but this does not address the primary safety priority.
Choice B rationale: Antiviral medications, such as acyclovir, are essential to inhibit viral replication and shorten the duration of the outbreak, yet they do not take precedence over immediate infection control measures.
Choice C rationale: Herpes zoster involves significant neuropathic pain due to nerve inflammation. While pain management is crucial for client comfort, it is considered a lower priority than preventing the spread of infection.
Choice D rationale: Herpes zoster is infectious until lesions have crusted over. The highest priority is preventing transmission to others, particularly those immunocompromised, through strict adherence to contact and potentially airborne precautions.
Correct Answer is B
Explanation
Choice A reason: Sitting forward with arms supported is the correct position for thoracentesis as it expands intercostal spaces and facilitates access to the pleural space.
Choice B reason: A persistent cough is not expected after thoracentesis. While a brief cough may occur due to pleural irritation, ongoing coughing may indicate a complication such as pneumothorax or pleural injury.
Choice C reason: Limiting activity post-procedure is appropriate to reduce strain and allow healing at the puncture site.
Choice D reason: A stinging sensation during needle insertion is expected and should be anticipated; local anesthesia helps minimize discomfort.
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