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?

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

Increase the elevation of the affected extremity.

Remove one of the weights.

Pull the client up in bed.

Answer and Explanation

The Correct Answer is D

D. The appropriate action would be to adjust the patient's position to restore the correct alignment and tension of the traction. This typically involves pulling the client up in bed to ensure that the weights hang freely and exert the necessary force for effective traction.

A It is not recommended to tie knots in the ropes as this action could disrupt the prescribed traction force and alignment.

B. It is helpful for other aspects of care but does not correct the traction issue caused by the weights resting on the floor.

C. This is not the correct action because it would decrease rather than increase the traction force, which is necessary for fracture alignment and healing.

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Correct Answer is ["C"]

Explanation

A To obtain reliable results, it is generally recommended to collect samples from different areas of the stool across multiple bowel movements rather than from a single sample.

detecting occult blood if it is present in the stool but not evenly distributed throughout. It also helps to reduce the chance of obtaining a false negative result.

C. Urine can interfere with the accuracy of fecal occult blood testing, leading to false positive results. Therefore, any sample that contains visible urine should be discarded to prevent inaccurate test results.

B. While gloves should be worn to maintain standard precautions and prevent direct contact with feces, sterile gloves are not required for this procedure. Standard medical examination gloves are sufficient to ensure hygiene and prevent contamination during sample collection.

D. The guaiac smear should be performed on a small portion of stool obtained from different areas within the bowel movement, not specifically from the outer edge of formed stool. The goal is to sample from different parts to increase the likelihood of detecting any occult blood present.

A. A client who has a compound fracture of the right femur B. A client who reports having fever, night sweats, and cough for 2 days C. An older adult client who was admitted with aspiration pneumonia D. A client who has diabetes mellitus and is presenting with acute ketoacidosis

Correct Answer is B

Explanation

B. Respiratory infections can spread via droplets, necessitating airborne precautions and isolation in a private negative pressure room to prevent transmission to other clients and healthcare workers.

A A compound fracture involves an open wound where the bone has punctured the skin. While this client may require isolation precautions due to the open wound, the primary concern is not infectious in nature.

C. Aspiration pneumonia can be caused by inhalation of oral or gastric contents into the lungs, leading to infection. Therefore, such a client does not require isolation.

D Acute ketoacidosis in diabetes mellitus is a metabolic emergency but is not typically contagious or requiring isolation precautions for infection control.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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