A nurse is caring for a client who is in skin traction. Which of the following actions should the nurse take?
Ensure the weights hang freely from the bed.
Inspect the client's skin every 12 hours for signs of breakdown.
Loosen the ropes of the pulleys when repositioning the client in bed.
Maintain 6.8 kg (15 lb) of weight for the skin traction.
The Correct Answer is A
Choice A Reason:
Ensuring that the weights hang freely from the bed is crucial in skin traction. The weights provide a constant and steady force necessary to achieve the therapeutic goal of traction, which is to align and stabilize a fractured bone. If the weights touch the floor or are obstructed, the traction will not be effective, potentially compromising the healing process.
Choice B Reason:
Inspecting the client's skin every 12 hours for signs of breakdown is important but not the highest priority. Skin breakdown can occur due to prolonged pressure from the traction equipment. Regular inspection helps in early identification and management of any skin issues, thus preventing complications such as infections or ulcers.
Choice C Reason:
Loosening the ropes of the pulleys when repositioning the client in bed is incorrect. The ropes should remain taut to maintain the correct amount of force on the affected limb. Loosening the ropes could disrupt the alignment and effectiveness of the traction, leading to inadequate treatment or further injury.
Choice D Reason:
Maintaining a specific weight for skin traction, such as 6.8 kg (15 lb), is a prescribed action based on the client's condition and the physician's orders. However, the exact weight to be used is determined by the healthcare provider and may vary from case to case. The nurse's role is to ensure that the prescribed weight is accurately maintained.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Nitroglycerin tablets should not be refilled every 12 months without consulting a healthcare provider. The potency of nitroglycerin tablets can decrease over time, and they should be replaced every 6 months.
Choice B Reason:
Storing nitroglycerin in the refrigerator is not recommended. The medication should be kept at room temperature, away from light and moisture, and in its original container to maintain its stability and potency.
Choice C Reason:
Sublingual nitroglycerin tablets should not be swallowed whole with a glass of water. They are designed to be dissolved under the tongue to provide rapid relief from chest pain.
Choice D Reason:
This is the correct instruction. If chest pain is not relieved after taking the first sublingual nitroglycerin tablet, it is standard practice to take a second tablet after 5 minutes. If the pain persists after three doses taken 5 minutes apart, emergency medical attention is required.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A Reason:
The first step in obtaining a capillary blood sample is to cleanse the site with an antiseptic swab. This is crucial to prevent infection and ensure that the sample is not contaminated. The antiseptic swab typically contains alcohol or another disinfectant that kills bacteria and other pathogens present on the skin surface.
Choice B Reason:
After cleansing, it is important to allow the site to dry completely before proceeding. This step is necessary because any residual antiseptic liquid can dilute the blood sample or interfere with the test results. Moreover, piercing wet skin can be more painful and may not provide a clean puncture for the blood sample.
Choice C Reason:
Once the site is dry, the nurse should pierce the puncture site quickly with a lancet. A quick puncture is less painful and produces a sufficient amount of blood for the test. The lancet should be used according to the manufacturer's instructions and should be disposed of safely after a single use to prevent needle-stick injuries and cross-contamination.
Choice D Reason:
After the puncture, the site should be squeezed gently to obtain a blood droplet. This action should be done carefully to avoid hemolysis of the blood cells, which can occur if the site is squeezed too hard. Hemolysis can affect the accuracy of the blood glucose reading.
Choice E Reason:
The final step is to apply the blood droplet to the test strip. The test strip should be held horizontally to the blood droplet to allow capillary action to draw the blood into the strip. The strip should not be pushed against the puncture site, as this can cause contamination or affect the sample volume.
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