A nurse is caring for a client who is in skeletal traction. Which of the following actions should the nurse take?

Unscrew the pins to cleanse the pin sites.

Remove the weights while turning the client in bed.

Loosen the rope knots holding the weights for 30 min if the client reports pain.

Ensure that there is at least 4.5 kg (10 lb) of weight applied to the client's traction.

Answer and Explanation

The Correct Answer is D

A. Unscrew the pins to cleanse the pin sites: Unscrewing the pins is incorrect as it can compromise the stability of the traction and increase the risk of infection. Pin site care should be performed according to the facility's protocol without disturbing the pins.
B. Remove the weights while turning the client in bed: Removing weights is incorrect as it can disrupt the alignment and effectiveness of the traction. Weights should be left in place to maintain proper traction and alignment.
C. Loosen the rope knots holding the weights for 30 min if the client reports pain: Loosening the rope knots is inappropriate and can interfere with the traction's effectiveness. Pain management should involve assessing the client's comfort and reviewing the traction setup, but not altering the traction itself.
D. Ensure that there is at least 4.5 kg (10 lb) of weight applied to the client's traction: This is correct as maintaining the appropriate amount of weight is crucial for proper skeletal traction. Ensuring that the prescribed weight is applied helps in achieving the desired therapeutic effect.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Provide a diet that is low in protein: This is incorrect because clients in sickle cell crisis require a well-balanced diet with adequate protein, along with increased fluid intake to help maintain hydration and reduce the risk of further complications.
B. Avoid administration of the influenza vaccine: This is incorrect because vaccination, including the influenza vaccine, is important for preventing infections that can exacerbate sickle cell crises.
C. Maintain the client on bed rest: This is correct because bed rest helps to reduce the energy expenditure and stress on the body, which can help manage pain and prevent further complications during a sickle cell crisis.
D. Decrease fluid intake to 1,500 mL daily: This is incorrect because increased fluid intake is crucial in sickle cell crisis to help prevent dehydration and promote proper blood flow, thereby reducing the risk of vaso-occlusive episodes.

A. Decreased bronchospasms B. Increased blood glucose level C. Increased blood pressure D. Decreased heart rate

Correct Answer is D

Explanation

A. Decreased bronchospasms: Metoprolol, a beta-blocker, does not typically decrease bronchospasms and may actually exacerbate them in susceptible individuals.
B. Increased blood glucose level: Metoprolol does not generally increase blood glucose levels. However, it can mask hypoglycemic symptoms in diabetic patients.
C. Increased blood pressure: Metoprolol is used to lower blood pressure, not increase it.
D. Decreased heart rate: This is correct as metoprolol is a beta-blocker that reduces heart rate by blocking beta-adrenergic receptors.

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A nurse is caring for a client who is in skeletal traction. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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