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.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Applying heat to a sprained ankle can increase swelling and should be avoided. Ice should be used instead to reduce swelling.
Choice B rationale
Wrapping the affected ankle with an elastic bandage helps to provide support, reduce swelling, and immobilize the joint.
Choice C rationale
Dangling the affected ankle can cause further injury and increase swelling. The ankle should be elevated to reduce swelling.
Choice D rationale
Bearing full weight on a sprained ankle can exacerbate the injury. The client should avoid putting weight on the ankle until it has healed sufficiently.
Correct Answer is A
Explanation
Choice A rationale
Placing white tape on the edges of stairs helps improve visibility and prevent falls, especially for older adults with vision impairments. This simple modification enhances safety in the home by making the edges of steps more noticeable, reducing the risk of missteps or trips.
Choice B rationale
Area rugs on wooden floors can be a tripping hazard, especially for older adults. They may cause slips or falls if they are not securely anchored, leading to potential injuries. It's generally safer to avoid using loose area rugs in high-traffic areas of the home.
Choice C rationale
Furnaces should be inspected annually, not every 2 years. Regular inspections ensure the furnace operates safely and efficiently, reducing the risk of carbon monoxide leaks or other hazards. An annual inspection is a key component of maintaining a safe home environment.
Choice D rationale
Running wires and cords under carpeting can create a fire hazard and increase the risk of electrical shock. This practice can damage the cords and cause overheating. It's safer to use cord protectors or secure cords along baseboards to prevent accidents.
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