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.

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

Pull the client up in bed.

Increase the elevation of the affected extremity.

Answer and Explanation

The Correct Answer is C

A. Remove one of the weights:
Removing a weight from skeletal traction can compromise the effectiveness of the traction, potentially leading to improper alignment and healing of the fracture. The weights are essential for maintaining the proper alignment and stability of the fractured bone, so altering them without proper medical guidance is not advisable.

B. Tie knots in the ropes near the pulleys to shorten them:
Tying knots in the ropes to shorten them is not a safe or appropriate method for adjusting traction. It can lead to uneven force distribution, poor alignment, and potential injury. Traction adjustments should be made by qualified personnel using proper equipment and methods.

C. Pull the client up in bed:
Pulling the client up in bed helps to ensure that the weights are properly suspended and not resting on the floor. This action helps maintain the effectiveness of the skeletal traction by ensuring that the appropriate amount of force is applied to the fracture. It also prevents potential complications associated with improperly positioned weights.

D. Increase the elevation of the affected extremity:
Increasing the elevation of the affected extremity might be indicated to reduce swelling or improve comfort but does not address the issue of weights resting on the floor. Proper positioning of the weights is crucial for effective traction and must be corrected to ensure optimal treatment outcomes.

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Correct Answer is A

Explanation

A) Instruct the client to lie flat:
After a lumbar puncture, clients are typically instructed to lie flat to reduce the risk of post-procedure headache, which can result from cerebrospinal fluid (CSF) leakage. Remaining flat helps the CSF to stabilize and promotes better healing.

B) Measure blood glucose every 2 hr:
Routine blood glucose monitoring is not required following a lumbar puncture unless the client has specific symptoms or a condition that warrants frequent monitoring. This intervention does not directly relate to the immediate post-procedure care for a lumbar puncture.

C) Instruct the client to expect tingling in their extremities:
Tingling in the extremities is not a normal expectation following a lumbar puncture. If a client experiences tingling, it could indicate a complication or an issue with the procedure that requires further evaluation by a healthcare provider.

D) Limit the client's fluid intake:
In fact, increasing fluid intake, particularly of fluids that contain electrolytes, is often recommended after a lumbar puncture to help replenish the CSF and reduce the risk of a post-procedure headache. Limiting fluid intake would be counterproductive to the recovery process.

A. Client no longer coughing up blood-tinged sputum B. Mantoux skin test revealing an induration of less than 1 mm C. Negative sputum cultures for acid-fast bacillus D. Positive Quantiferon-TB Gold test (negative)

Correct Answer is C

Explanation

A) Client no longer coughing up blood-tinged sputum:
While the absence of blood-tinged sputum might indicate an improvement in symptoms, it does not necessarily mean that the client is no longer infectious. Infectiousness is determined by the presence or absence of the bacteria in sputum cultures, not just the symptoms.

B) Mantoux skin test revealing an induration of less than 1 mm:
A Mantoux test indicating less than 1 mm of induration might suggest a low likelihood of active tuberculosis, but it does not confirm that the client is no longer infectious. The Mantoux test is used to detect exposure, not to assess the infectious status.

C) Negative sputum cultures for acid-fast bacillus:
Negative sputum cultures for acid-fast bacillus are the most definitive indicator that a client with tuberculosis is no longer infectious. This means that the bacteria causing tuberculosis are no longer present in the sputum, reducing the risk of transmission to others.

D) Positive Quantiferon-TB Gold test (negative):
A positive Quantiferon-TB Gold test indicates exposure to tuberculosis, but it does not determine if the client is infectious. The test assesses immune response to TB antigens, not active disease or infectious status.

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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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