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 A
Explanation
Choice A reason:
Providing oral care before meals is crucial for a client with dysphagia after a stroke. Oral care can help clear the mouth of bacteria and food debris, reducing the risk of aspiration and improving the client's ability to taste and swallow food. According to the American Stroke Association, maintaining good oral hygiene is part of managing dysphagia to prevent complications like pneumonia.
Choice B reason:
Instructing the client to tilt their head back to facilitate swallowing is not recommended for individuals with dysphagia following a stroke. This position can increase the risk of aspiration, as it may allow food or liquid to enter the airway. Instead, the client should be encouraged to maintain an upright position, and in some cases, to tuck the chin slightly to protect the airway during swallowing.
Choice C reason:
Encouraging the use of a straw is generally not advised for clients with dysphagia. Using a straw can increase the speed at which liquid enters the mouth, which can be difficult to control and may lead to aspiration. The American Speech-Language-Hearing Association suggests that taking small sips and bites and avoiding straws can help manage dysphagia more safely.
Choice D reason:
Scheduling physical therapy directly before meals is not ideal for clients with dysphagia. Physical therapy can be fatiguing, and fatigue may worsen the client's ability to control the muscles needed for safe swallowing. It's better to schedule therapy sessions at a time when the client is well-rested and alert, ensuring they have the energy and focus required for safe eating practices²
.
Correct Answer is D
Explanation
Choice A Reason:
Peripheral edema is the swelling of tissues, typically in the lower limbs, due to the accumulation of fluid. It's not a common sign of anaphylaxis. Anaphylaxis usually involves symptoms like hives, itching, and flushed or pale skin. Peripheral edema can be associated with other conditions such as heart failure, kidney disease, or venous insufficiency.
Choice B Reason:
Hypertension, or high blood pressure, is not typically a symptom of anaphylaxis. During an anaphylactic reaction, the patient is more likely to experience hypotension, or low blood pressure, due to vasodilation and the release of mediators from mast cells and basophils. Hypertension might be present in other medical scenarios but not usually in anaphylaxis.
Choice C Reason:
Pallor, which refers to paleness or a decrease in skin pigmentation, is not a direct symptom of anaphylaxis. Anaphylaxis can cause flushed or pale skin, but this is due to the sudden drop in blood pressure and shock, rather than a primary change in skin color. Pallor is more commonly associated with anemia or blood loss.
Choice D Reason:
Pruritus, or itching, is a common symptom of anaphylaxis and is often accompanied by hives and other skin reactions. It occurs due to the release of histamine and other chemicals from mast cells in the skin. Pruritus is an early warning sign and can precede more severe symptoms of anaphylaxis.
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