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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Black-colored stools can indicate gastrointestinal bleeding, which is a potential side effect of corticosteroids like betamethasone. It is not considered harmless and should be reported to the healthcare provider immediately.

Choice B reason: A low-potassium diet is not specifically required for clients taking betamethasone. Corticosteroids can cause potassium loss, so it is important to monitor potassium levels, but not necessarily restrict intake unless directed by the healthcare provider.

Choice C reason: The correct answer is c because taking corticosteroids like betamethasone every other day can help reduce the risk of adrenal suppression, a common side effect of long-term corticosteroid use. This dosing schedule allows the adrenal glands to recover and maintain their function.

Choice D reason: Taking betamethasone before bedtime is not specifically recommended for its effectiveness. The dosing schedule should be based on the healthcare provider's instructions and tailored to the client's condition and response to the medication.

A. Lactulose B. Triamterene C. Sodium polystyrene D. Acetylcysteine

Correct Answer is C

Explanation

Choice A reason: Lactulose is a laxative used to treat constipation and hepatic encephalopathy by reducing blood ammonia levels, but it is not effective in lowering serum potassium levels. Therefore, it would not be the appropriate medication for treating hyperkalemia.

Choice B reason: Triamterene is a potassium-sparing diuretic, which means it helps the body retain potassium. Administering Triamterene in a client with high potassium levels (hyperkalemia) would exacerbate the condition rather than improve it. Hence, it is not a suitable choice for this scenario.

Choice C reason: Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia by binding to potassium in the intestines and facilitating its removal from the body through feces. It effectively reduces serum potassium levels, making it the appropriate medication for a client with hyperkalemia.

Choice D reason: Acetylcysteine is used primarily as a mucolytic agent to break down mucus in the airways or as an antidote for acetaminophen (paracetamol) overdose. It does not have any effect on serum potassium levels and is not suitable for treating hyperkalemia.

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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?

Nursing Test Bank

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