A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?
Remove the weights before changing the client's bed linens.
Instruct the client to use their elbows to reposition.
Check pressure points every 12 hours.
Provide the client with a trapeze bar.
The Correct Answer is D
Choice A reason: Removing the weights before changing the client's bed linens is not recommended. The weights are an integral part of the traction system and removing them could disrupt the traction, potentially causing harm or discomfort to the client. The weights must be maintained to ensure the effectiveness of the skeletal traction.
Choice B reason: Instructing the client to use their elbows to reposition themselves could be helpful, but it is not the primary action the nurse should take. While maintaining some degree of mobility is important, the nurse must ensure that the traction setup is not disturbed during any movement.
Choice C reason: Checking pressure points every 12 hours is important to prevent skin breakdown and ulcers, especially in immobilized patients. However, this is a routine action and not specific to the care of a client with skeletal traction. The nurse should check pressure points more frequently, considering the increased risk of pressure sores in immobilized patients.
Choice D reason: Providing the client with a trapeze bar is the correct action. A trapeze bar allows the client to independently reposition themselves while maintaining the integrity of the traction. It helps the client to move and shift weight, which can aid in preventing complications such as pressure ulcers and muscle atrophy. It also gives the client a sense of control and independence in their care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While wearing gloves is a standard precaution to prevent contamination and protect the nurse from potential pathogens, the gloves used for collecting a guaiac smear sample do not need to be sterile. Clean, non-sterile gloves are typically sufficient for this procedure.
Choice B reason: It is crucial to discard any samples that contain urine because urine can interfere with the results of the fecal occult blood test (FOBT). The presence of urine can cause false positives due to the peroxidase activity in urine, which can lead to unnecessary further testing.
Choice C reason: Collecting three samples from a single bowel movement is not recommended. Instead, it is advised to collect samples from three separate bowel movements to increase the likelihood of detecting intermittent bleeding, which is common in conditions like colorectal cancer.
Choice D reason: Taking the sample from the outer edge of formed stool is not the best practice. The sample should be taken from different areas of the stool to ensure a representative sample, as blood may not be uniformly distributed throughout the stool.
Correct Answer is ["B","C","E"]
Explanation
Choice A reason:Frequent exposure to low-volume noise is not typically a risk factor for hearing loss. Hearing loss is more commonly associated with prolonged exposure to high-volume noise, which can damage the delicate structures within the ear.
Choice B reason: Chronic infections of the middle ear, such as chronic otitis media, can lead to hearing loss. These infections can cause persistent inflammation and fluid buildup, which may damage the middle ear structures over time, leading to conductive hearing loss.
Choice C reason: Perforation of the eardrum, or a ruptured eardrum, can result in hearing loss. The eardrum is essential for the proper conduction of sound waves to the inner ear. A perforation disrupts this process and can reduce hearing ability until the eardrum heals or is surgically repaired.
Choice D reason: Being born with a high birth weight is not a known risk factor for hearing loss. Hearing loss at birth is more commonly associated with genetic factors, prenatal and perinatal infections, and complications during birth.
Choice E reason: The use of a loop diuretic can be a risk factor for hearing loss. These medications can have ototoxic effects, especially when administered in high doses or with rapid intravenous infusion, potentially leading to temporary or permanent hearing loss.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.