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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Wear a simple face mask when caring for the client: This is incorrect because pertussis is highly contagious and requires more stringent precautions, such as an N95 mask, to prevent transmission.
B. Wear a gown when caring for the client: This is incorrect as wearing a gown is not typically required for pertussis unless there is a risk of direct contact with respiratory secretions.
C. Place the client in a negative air pressure room: This is incorrect because pertussis does not require negative air pressure; it is transmitted through droplets, not airborne particles.
D. Wear an N95 mask when in the client's room: This is correct because an N95 mask provides the necessary protection against respiratory droplets that can transmit pertussis, ensuring proper protection for healthcare workers.
Correct Answer is D
Explanation
A. Elevate legs on pillows when in bed: This is incorrect because elevating the legs can reduce blood flow in peripheral arterial disease, and it is generally advised to keep the legs at the level of the heart or lower to promote better circulation.
B. Apply heating pad for 15 min twice per day: This is incorrect because applying heat directly to the legs is not recommended as it can lead to burns or other complications, especially in patients with peripheral vascular issues.
C. Wear knee-high support hose during the day: This is incorrect because support hose can sometimes exacerbate symptoms of peripheral arterial disease by restricting blood flow. Compression stockings are generally not recommended.
D. Begin an exercise program that includes walking: This is correct because walking and other forms of exercise improve circulation and help alleviate symptoms of peripheral arterial disease by promoting better blood flow and cardiovascular health.
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