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 B
Explanation
Choice A reason: Brudzinski's sign is an indicator of meningitis, where flexion of the neck causes involuntary flexion of the hips and knees. This sign is not related to hypocalcemia and is more specific to central nervous system infections.
Choice B reason: Chvostek's sign is a clinical sign of hypocalcemia. It is elicited by tapping on the facial nerve in front of the ear, which causes twitching of the facial muscles. This sign indicates neuromuscular irritability due to low calcium levels and is a key indicator for diagnosing hypocalcemia.
Choice C reason: Cullen's sign is a superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is associated with acute pancreatitis and intra-abdominal bleeding, not hypocalcemia. Therefore, it is not an appropriate sign to monitor for in clients with hypocalcemia.
Choice D reason: Kernig's sign is another indicator of meningitis. It involves pain and resistance to knee extension when the hip is flexed. Like Brudzinski's sign, it is specific to meningitis and is not related to hypocalcemia. Monitoring for this sign would not be relevant for a client with low calcium levels.
Correct Answer is D
Explanation
Choice A reason: Reviewing relaxation techniques can be beneficial for managing anxiety during an asthma attack, but it is not the highest priority in an acute situation.
Choice B reason: Providing immediate rest can help the client conserve energy and reduce the work of breathing, but it does not address the underlying cause of the asthma exacerbation.
Choice C reason: Reminding the client not to try to talk helps reduce the work of breathing, but it is not the most urgent intervention.
Choice D reason: The correct answer is d because administering a short-acting beta-adrenergic medication, such as albuterol, is the highest priority. These medications act quickly to relax the bronchial muscles, reduce bronchospasm, and improve airflow, which is critical in an acute asthma exacerbation.
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