A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction.
Which of the following actions should the nurse take?
Ensure the client's weights are hanging freely from the bed.
Check the client's bony prominences every 12 hr.
Cleanse the client's pin sites with povidone-iodine.
Loosen the knots on the ropes if the client is experiencing pain.
The Correct Answer is A
Choice A rationale
Ensuring the client's weights are hanging freely from the bed is crucial in maintaining the proper amount of traction force. This prevents complications and ensures that the traction is effective in reducing the fracture and alleviating pain.
Choice B rationale
Checking the client's bony prominences every 12 hours is important for preventing pressure ulcers and skin breakdown. However, the timing might need to be more frequent depending on the client's overall health and risk factors.
Choice C rationale
Cleansing the client's pin sites with povidone-iodine is a common practice to prevent infection. However, current guidelines often recommend alternative cleaning solutions, such as chlorhexidine, due to better evidence of efficacy.
Choice D rationale
Loosening the knots on the ropes if the client is experiencing pain can compromise the effectiveness of the traction. Adjustments should be made by a healthcare professional to ensure the correct amount of force is applied without causing additional harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,A,B,C
No explanation
Correct Answer is D
Explanation
Choice A rationale
Hearing tests are important for children, but they are typically conducted earlier in childhood to detect any hearing impairments that may affect speech and language development.
Choice B rationale
Reading screenings are not typically part of routine health checks at this age and are more related to educational assessments.
Choice C rationale
Eye screenings are also important but are generally performed earlier in childhood to identify and correct vision issues that could impact learning.
Choice D rationale
Scoliosis screening is appropriate for a 10-year-old as it is a crucial period for identifying spinal curvature abnormalities that can develop during rapid growth spurts. .
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