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 client's bed.

Maintain 6.8 kg (15 lb) of weight for the client's skin traction.

Loosen the ropes of the pulleys when repositioning the client in bed.

Inspect the client's skin every 12 hr for signs of breakdown.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Ensuring the weights hang freely prevents interference with the traction, which helps maintain alignment and reduce pain.

Choice B rationale

Maintaining 6.8 kg (15 lb) of weight is not specific to skin traction and could be inappropriate, as the weight should be based on the physician's orders.

Choice C rationale

Loosening the ropes of the pulleys when repositioning the client can interfere with the effectiveness of the traction.

Choice D rationale

Inspecting the client's skin every 12 hours for signs of breakdown is not frequent enough; skin should be checked more often to prevent complications.

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Correct Answer is C

Explanation

Choice A rationale

Emptying the ileostomy bag every 4 to 6 hours is incorrect as the frequency depends on the individual's output, which can be higher, requiring more frequent emptying.

Choice B rationale

Using moisturizing soap to clean around the stoma is not recommended as it can interfere with the adhesion of the wafer. Mild, non-moisturizing soap should be used instead.

Choice C rationale

Cutting the wafer opening one-fourth of an inch larger than the stoma is correct as it allows for proper fitting and prevents constriction of the stoma, reducing the risk of skin irritation.

Choice D rationale

Using a skin sealant before applying the bag is recommended to protect the skin and improve the adhesion of the ostomy appliance. .

A. "I shouldn't travel by plane because of airport security.”. B. "I should have an MRI, rather than a CAT Scan, if necessary.”. C. "I'll hold my cell phone against the ear on the opposite side of my body.”. D. "I'll make sure I stay away from microwave ovens.”.

Correct Answer is C

Explanation

Choice A rationale

Traveling by plane is safe for individuals with pacemakers. Security procedures at airports can be managed with proper precautions and communication with security staff.

Choice B rationale

MRIs are generally contraindicated for individuals with pacemakers due to the strong magnetic fields. CAT scans are usually a safer alternative.

Choice C rationale

Holding the cell phone on the opposite side of the pacemaker is recommended to avoid potential interference with the device.

Choice D rationale

Modern microwave ovens are well shielded and do not pose a risk of interference with pacemakers. Individuals with pacemakers can safely use microwaves.

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

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