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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Involution is the process by which the uterus returns to its nonpregnant size and function after delivery.
Choice A is not correct because evolution refers to the gradual development of something.
Choice B is not correct because decrement refers to a reduction in size or value.
Choice C is not correct because progression refers to the process of developing or moving gradually toward a more advanced state.
Correct Answer is C
Explanation
This is an antibiotic ointment that is applied to the eyes of newborns to prevent ophthalmia neonatorum, a serious eye infection caused by gonorrhea.
Ophthalmia neonatorum can cause blindness if left untreated and can occur even if the mother does not have symptoms of gonorrhea.
Erythromycin is the only drug approved by the FDA for this purpose and is mandated in most states.
Choice A.
Nystatin is incorrect, as this is an antifungal medication that is used to treat oral thrush or diaper rash in newborns, not eye infections.
Choice B.
Ceftriaxone is incorrect, as this is an antibiotic injection that is used to treat systemic gonorrhea infections in adults or newborns, not eye infections.
Choice D.
Ofloxacin is incorrect, as this is an antibiotic eye drop that is used to treat bacterial conjunctivitis in older children and adults, not ophthalmia neonatorum in newborns.
Therefore, choice C is the best answer to this question.
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