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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Monitoring for at least 150 mL of drainage every hour is excessive; the expected drainage is around 70-100 mL per hour. This amount indicates a potential complication.
Choice B rationale
Replacing the unit when the drainage chamber is full is correct to maintain the efficiency of the closed-chest tube drainage system and prevent overflow.
Choice C rationale
Clamping the tube for 30 minutes every 8 hours can cause tension pneumothorax and is not recommended.
Choice D rationale
Pinning the tubing to the client's bed sheets can cause kinks and obstruction, which can lead to complications.
Correct Answer is B
Explanation
Choice A rationale
Isolating the client in their room is not necessary for managing GERD. Isolation measures are typically used for contagious diseases, not for GERD, which is a non-infectious condition.
Choice B rationale
Encouraging the client to ambulate with a staff member helps promote gastrointestinal motility and reduce the risk of reflux. Physical activity can aid in digestion and reduce GERD symptoms.
Choice C rationale
Trazodone is an antidepressant and is not typically prescribed for managing GERD. It is not relevant to the care plan for a client with GERD.
Choice D rationale
Applying bilateral wrist restraints is not indicated for GERD management. Restraints are used for patients who pose a risk to themselves or others, not for those with GERD. .
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