A nurse is caring for a client who has skeletal traction for the treatment of a femur fracture.
Which of the following actions should the nurse take?
Position the weights on the traction so they are touching the head of the client's bed
Encourage isometric exercises every 8 hr
Administer pain medication to the client before performing pin care
Assist the client to shift position every 4 hr.
The Correct Answer is C
Choice A reason:
Placing traction weights so they touch the head of the bed disrupts the effectiveness of the traction system. Skeletal traction relies on a continuous pulling force to maintain proper alignment of the fractured femur. If the weights are resting on any surface, the force is interrupted, which can lead to complications such as malunion or delayed healing. The weights must hang freely at all times to ensure therapeutic benefit.
Choice B reason:
Isometric exercises are beneficial for maintaining muscle tone and promoting circulation during immobilization. However, while this is a supportive intervention, it is not the most critical or immediate nursing action in the context of skeletal traction. Encouraging exercises every 8 hours is appropriate, but it does not directly address the most urgent or discomfort-related aspect of care.
Choice C reason:
Pin care is a routine but potentially painful procedure associated with skeletal traction. Administering pain medication beforehand is a priority nursing action because it ensures client comfort, reduces anxiety, and promotes cooperation during the procedure. This intervention reflects both compassionate care and adherence to best practices in pain management and infection prevention.
Choice D reason:
Repositioning a client in skeletal traction must be done with extreme caution to avoid disrupting the traction setup. Assisting the client to shift position every 4 hours may inadvertently alter the alignment or tension of the traction apparatus. While pressure injury prevention is important, repositioning must be coordinated carefully and is not the most appropriate standalone action in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should instruct the parents to bring the infant’s favorite blanket to the hospital.
This can provide comfort and a sense of familiarity for the infant during their hospital stay.
Choice A is incorrect because reading a story about hospitalization to an 8- month-old infant may not be developmentally appropriate.
Choice C is incorrect because parents are usually allowed to stay with their infant during hospitalization.
Choice D is incorrect because manipulating the infant’s bedtime based on the hospital’s visiting hours is not necessary.
Correct Answer is C
Explanation
Elevated levels of MSAFP may indicate that the baby is at risk of a neural tube defect, like spina bifida.
However, further testing is required to confirm the results and determine the cause of the elevated levels.
Choice A is incorrect because low levels of MSAFP may indicate a risk for Down syndrome, not elevated levels.
Choice B is incorrect because while elevated levels of MSAFP may indicate a risk for neural tube defects, further testing is required to confirm this.
Choice D is incorrect because while repeating the test may be necessary, further testing beyond just repeating the MSAFP screening may also be required.
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