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 ["3.8"]
Explanation
Step 1: lb ÷ (2.2 lb/kg) = 10 kg.
Step 2:.5 mg/kg/day × 10 kg = 15 mg/day.
Step 3: mg/day ÷ 4 doses/day = 3.75 mg/dose.
Step 4:.75 mg ÷ 1 mg/mL = 3.75 mL per dose.
The calculated answer is 3.8 mL (rounded to the nearest tenth).
Correct Answer is D
Explanation
Choice A rationale
Introducing well-cooked table foods should begin around 8-10 months of age when the baby is ready for finger foods and has developed better chewing skills.
Choice B rationale
Starting solid foods at 3 months old is too early and can interfere with breastfeeding or formula feeding, increasing the risk of allergies and digestive issues.
Choice C rationale
Cow's milk should not be introduced until 12 months of age, as infants need the nutrients from breast milk or formula during their first year for optimal growth.
Choice D rationale
It is recommended to wait until the baby is at least 6 months old before introducing fruit juice, and even then, it should be given in limited quantities to avoid excessive sugar intake.
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