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 C
Explanation
Choice A reason: Injecting the medication into the abdomen above the level of the iliac crest is not recommended. The preferred sites for subcutaneous injections are the fatty tissue over the triceps, the abdomen from below the costal margin to the iliac crests, and the anterior aspects of the thighs. The area above the iliac crest may not have sufficient subcutaneous tissue, which could affect the absorption of the medication.
Choice B reason: Using a 1-inch needle can be appropriate depending on the client's body mass. For most adults, a 5/8-inch to 1-inch needle is recommended for subcutaneous injections to ensure the medication is delivered to the subcutaneous tissue and not into the muscle.
Choice C reason: Using a 25-gauge needle is the appropriate action when administering heparin subcutaneously. A smaller gauge needle, such as 25-gauge, is typically used for subcutaneous injections to minimize discomfort and tissue trauma.
Choice D reason: Massaging the injection site after administration of the medication is not recommended when administering heparin subcutaneously. Massaging the site can cause the medication to be absorbed more quickly than intended and may increase the risk of bleeding.
Correct Answer is B
Explanation
Choice A reason: This statement does not indicate a need for further instruction. It is recommended to wait at least 30 minutes after taking alendronate before taking other medications to ensure proper absorption of the drug.
Choice B reason: This statement indicates a need for further instruction. Alendronate should be taken with plain water, not milk. Milk and other dairy products can interfere with the absorption of alendronate due to their calcium content.
Choice C reason: This statement does not indicate a need for further instruction. Patients are advised to remain upright for at least 30 minutes after taking alendronate to prevent esophageal irritation or ulceration.
Choice D reason: This statement does not indicate a need for further instruction. Periodic bone density tests are a standard part of monitoring the effectiveness of osteoporosis treatment.
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