A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown?
Apply lotion to the skin around the edges of the splint.
Turn the client every 4 hr.
Pad the top of the splint with protective dressings.
The nurse should apply a footplate to the bed.
The Correct Answer is C
Choice A reason: Applying lotion to the skin around the edges of the splint may increase moisture and friction, which can contribute to skin breakdown. It is better to use protective dressings to reduce friction.
Choice B reason: Turning the client every 4 hours is not frequent enough. Clients in skeletal traction should be repositioned frequently, typically every 2 hours, to prevent pressure ulcers and maintain skin integrity.
Choice C reason: The correct answer is c because padding the top of the splint with protective dressings helps reduce friction and pressure on the skin, preventing skin breakdown and ensuring the client's comfort.
Choice D reason: Applying a footplate to the bed is not directly related to preventing skin breakdown. The primary focus should be on reducing friction and pressure around the splint.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: While early CPR is crucial, the AED should be attached as soon as it is available to analyze the heart rhythm and provide a shock if needed. Delaying the use of the AED can reduce the chances of successful resuscitation.
Choice B reason: In adults, the carotid pulse is typically checked, not the brachial pulse. The brachial pulse is more commonly assessed in infants.
Choice C reason: The correct answer is c because providing chest compressions at a rate of 100-120 compressions per minute is the recommended rate for effective CPR. High-quality chest compressions are essential for maintaining circulation during cardiac arrest.
Choice D reason: The recommended ratio of chest compressions to rescue breaths is 30:2, not 50:2. Performing 50 compressions before providing rescue breaths is not aligned with current CPR guidelines.
Correct Answer is A
Explanation
Choice A reason: The correct answer is a because refusing to look at the dressing or surgical incision can indicate that the client is having difficulty accepting the loss of her breast. This behavior may suggest that the client is struggling with body image issues, grief, or denial about the changes to her body.
Choice B reason: Requesting pain medication every 3 hours is a common postoperative behavior to manage pain and does not necessarily indicate difficulty adjusting to the loss of a breast. Pain management is a normal part of recovery.
Choice C reason: Asking questions about the information on the postoperative care pamphlet demonstrates an interest in understanding and managing her care. This behavior indicates that the client is engaged in her recovery process, rather than struggling to adjust.
Choice D reason: Performing arm exercises once or twice each day shows that the client is following postoperative care instructions and is actively participating in her rehabilitation. This behavior does not suggest difficulty adjusting to the loss of her breast.
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