A nurse is caring for a client who has a prescription for balanced skeletal traction with a Thomas splint for the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint?
Remove the weights for a few minutes each hour.
Apply lotion to the skin under the edges of the splint.
Apply a foot plate to the bed.
Reposition the client to keep him from staying in the same position in bed.
The Correct Answer is D
A. Removing the weights periodically helps relieve pressure on the skin but dosen't prevent pressure points from developing.
B. Applying lotion may not effectively prevent pressure points and could potentially lead to skin irritation.
C. Applying a foot plate to the bed is not directly related to preventing pressure points around the edges of the splint.
D. Repositioning the client is important for overall comfort as well as preventing complications by altering pressure points.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Inserting sterile packing into the nares is not indicated in this situation. Clear fluid drainage from the nose may be cerebrospinal fluid (CSF), and packing could cause further complications.
B. Allowing the drainage to drip onto a sterile gauze pad is the appropriate initial action. Clear fluid drainage from the nose after a traumatic event may be CSF, which can indicate a skull fracture and damage to the meninges. Collecting the fluid on a sterile gauze pad can help confirm the presence of CSF.
C. Suctioning the nose with a bulb syringe is not recommended because it can introduce contaminants into the nasal passages and potentially worsen the injury.
D. Obtaining a culture of the specimen using sterile swabs is a consideration once the presence of CSF is confirmed. However, the initial priority is to identify and collect the clear fluid drainage.
Correct Answer is B
Explanation
A. Inability to move toes may be a sign of tightness in the cast, but it is not the first finding to be expected if the cast is too tight.
B. Pallor of the toes indicates compromised blood flow and is the earliest sign of circulatory impairment due to tightness of the cast.
C. Change in temperature of the toes may be a sign of impaired circulation, but it is not the earliest finding to be expected.
D. Edema of the toes may occur as a result of compromised circulation, but it is not the first finding to be expected if the cast is too tight.
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