A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?

Remove one of the weights.

Pull the client up in bed.

Increase the elevation of the affected extremity.

Tie knots in the ropes near the pulleys to shorten them.

Answer and Explanation

The Correct Answer is A

A) Remove one of the weights: This is the appropriate action. If the weights are resting on the floor, it indicates that the traction is ineffective, and removing one weight may be necessary to restore proper traction. However, the nurse should first verify the prescribed amount of weight with the healthcare provider before making adjustments.

B) Pull the client up in bed: While it may be necessary to reposition the client, pulling them up in bed does not address the issue of the weights resting on the floor and could potentially cause discomfort or injury.

C) Increase the elevation of the affected extremity: While elevating the extremity may be beneficial for swelling or comfort, it does not resolve the issue of ineffective traction caused by the weights on the floor.

D) Tie knots in the ropes near the pulleys to shorten them: This action is inappropriate. Tying knots in the ropes could interfere with the proper function of the traction system and is not a safe or effective solution to the problem.

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Correct Answer is D

Explanation

A) Check settings of the CPM machine every 12 hr: This is not frequent enough. The nurse should check the settings of the CPM machine more regularly, typically before each use or every few hours, to ensure the settings are appropriate for the client's therapy.

B) Increase the range of motion rapidly when the CPM machine is used intermittently: This approach is not safe. The range of motion should be increased gradually based on the healthcare provider's orders and the client's tolerance to avoid injury or discomfort.
C) Store the CPM machine on the floor when not in use: Storing the CPM machine on the floor can pose safety hazards, such as tripping or damage to the machine. It should be stored in a safe, designated area when not in use.

D) Turn the CPM machine off while the client is eating: This is an appropriate action. It allows the client to eat comfortably and without obstruction, ensuring they can focus on eating without the machine interfering. Once the client has finished eating, the CPM machine can be turned back on to continue therapy.

A. Wear a surgical mask when providing care to the client. B. Perform a Mantoux skin test on the client. C. Assign the client to a negative-pressure airflow room. D. Recommend that the client's family members receive antiviral therapy.

Correct Answer is A

Explanation

A) Wear a surgical mask when providing care to the client.: This is the appropriate action because pertussis (whooping cough) is highly contagious and is transmitted via respiratory droplets. Wearing a surgical mask helps to protect the nurse and other staff from inhaling these droplets when in close contact with the client.

B) Perform a Mantoux skin test on the client.: The Mantoux skin test is used for detecting tuberculosis exposure, not pertussis. Therefore, this action is not relevant for a client with pertussis and does not address the immediate needs of the situation.

C) Assign the client to a negative-pressure airflow room.: Negative-pressure rooms are typically used for airborne precautions, such as for tuberculosis or COVID-19. Pertussis requires droplet precautions, not airborne precautions, making this option unnecessary.

D) Recommend that the client's family members receive antiviral therapy.: While family members may need prophylactic antibiotics, antiviral therapy is not indicated for pertussis. Instead, they should receive antibiotics like azithromycin or erythromycin to prevent the spread of the disease.

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