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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Presence of gag reflex: This is normal after a bronchoscopy as the gag reflex indicates that the client is recovering from sedation.
B. Sore throat: This is a common and expected finding after a bronchoscopy due to irritation of the throat.
C. Facial edema: This is correct as facial edema may indicate an allergic reaction or complication, and it should be reported to the provider immediately.
D. Blood pressure 110/78 mm Hg: This is within the normal range and does not typically require reporting unless there are other symptoms present.
Correct Answer is B
Explanation
A. Suggest fresh fruits and vegetables: This is incorrect because clients with HIV, especially those with immunosuppression, might be at increased risk for foodborne illnesses from fresh produce. Proper food handling and possibly cooked vegetables might be recommended instead.
B. Offer small, frequent meals: This is correct because small, frequent meals can help manage symptoms like nausea or loss of appetite, which are common in clients with HIV.
C. Provide a diet of pureed foods: This is unnecessary unless the client has specific swallowing difficulties. Generally, pureed foods are not required unless indicated by the client's condition.
D. Encourage fluids with meals: This is incorrect as consuming large amounts of fluids with meals may lead to early satiety, which is not ideal for clients needing to maintain or gain weight.
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