A nurse is assisting with the care of an adolescent client who is in skeletal traction for the treatment of a fractured femur. Which of the following actions should the nurse take?

Gently lift the traction weights off the floor when repositioning the client.

Reduce intake of foods containing fiber while nonambulatory.

Perform passive range-of-motion exercises to the affected extremity every 2 hours.

Apply protective padding to the end of the pin sites.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Gently lift the traction weights off the floor when repositioning the client. Rationale: This choice is not recommended in the care of a client in skeletal traction. Traction weights should never be lifted off the floor as they provide the necessary counter traction to align and immobilize the fractured bone. Lifting the weights could disrupt the traction and jeopardize the healing process.
Choice B rationale:
Reduce intake of foods containing fiber while nonambulatory. Rationale: While constipation can be a concern for clients in skeletal traction due to decreased mobility, reducing fiber intake is not the appropriate intervention. Adequate fiber intake is important to promote regular bowel movements and prevent constipation. Hydration and mobility exercises are more suitable approaches to manage constipation.
Choice C rationale:
Perform passive range-of-motion exercises to the affected extremity every 2 hours. Rationale: Passive range-of-motion exercises are important to maintain joint mobility and prevent muscle atrophy in a nonambulatory client. However, performing these exercises every 2 hours might be excessive and could cause unnecessary discomfort for the client. Range-of-motion exercises are usually done every 4 to 8 hours to strike a balance between maintaining joint health and providing rest.
Choice D rationale:
Apply protective padding to the end of the pin sites. Rationale: This is the correct choice. Applying protective padding to the end of the pin sites is crucial to prevent pressure ulcers and infection. The pin sites are potential entry points for bacteria, and protecting them helps reduce the risk of infection. Padding also prevents pressure on the skin and underlying tissues, reducing the potential for pressure injuries.

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Correct Answer is C

Explanation

Choice A rationale:
This medication can cause ringing in the ears (Choice A) is not a common side effect of amoxicillin. Ringing in the ears (tinnitus) is not typically associated with the use of this antibiotic.
Choice B rationale:
This medication can cause muscle pain (Choice B) is not a common side effect of amoxicillin. Muscle pain is not among the usual adverse reactions associated with its use.
Choice C rationale:
This medication can cause loose stools (Choice C) is a relevant side effect of amoxicillin. Antibiotics, including amoxicillin, can disrupt the normal balance of gut bacteria, potentially leading to gastrointestinal disturbances such as diarrhea or loose stools.
Choice D rationale:
This medication can cause blurred vision (Choice D) is not a common side effect of amoxicillin. Blurred vision is not a typical adverse effect associated with the use of this antibiotic.

A. A 6-month-old infant who has a spiral fracture to a lower extremity. B. A 9-month-old infant who has been exposed to bedbugs and has cellulitis. C. A 4-year-old preschooler who has a rivalry with their siblings. D. A 24-month-old toddler who experiences occasional incontinence.

Correct Answer is A

Explanation

Choice A rationale:
The nurse should report the finding of a 6-month-old infant with a spiral fracture to a lower extremity to local authorities. Spiral fractures in infants, especially those who are not yet independently mobile, raise concerns about possible child abuse or non-accidental trauma. The unique pattern of spiral fractures is often associated with twisting forces, which are unlikely to occur accidentally in infants who cannot perform such movements. Reporting such cases is essential to ensure the safety and well-being of the child.
Choice B rationale:
A 9-month-old infant exposed to bedbugs and cellulitis is not an emergency that requires reporting to local authorities. While cellulitis can be serious, it is not an immediate threat to the child's safety, and the focus should be on providing appropriate medical care.
Choice C rationale:
A 4-year-old preschooler with rivalry among siblings does not indicate a need for reporting to local authorities. Sibling rivalry is a common occurrence in families and does not pose a threat to the child's safety. It is a social and developmental issue that can be addressed within the family.
Choice D rationale:
A 24-month-old toddler experiencing occasional incontinence does not require reporting to local authorities. Occasional incontinence can be a normal part of toddler development as they learn to control their bladder. It does not indicate abuse or immediate danger to the child.

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A nurse is assisting with the care of an adolescent client who is in skeletal traction for the treatment of a fractured femur. Which of the following actions should the nurse take?

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