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 C
Explanation
The nurse should recommend an increased fiber and fluid intake in the diet to help relieve constipation during pregnancy.
Eating more foods with fiber such as fruits, vegetables, whole grains, beans, nuts, and seeds can help fight constipation123.
Regular use of glycerine suppositories or laxatives is not recommended during pregnancy without consulting a healthcare provider first4.
Maintenance of good posture is not directly related to relieving constipation.
Correct Answer is D
Explanation
“Implantation occurs between two and three weeks after conception.” This statement is incorrect because implantation usually occurs about 6 to 10 days after conception.
Choice A is correct because bleeding or spotting can accompany implantation.
Choice B is correct because sperm can remain viable in the woman’s reproductive tract for 2 to 3 days.
Choice C is correct because fertilization typically takes place in the outer third of the fallopian tube.
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