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 C
Explanation
Choice A rationale
The supine position with the head of the bed flat does not facilitate the safe and effective draining of fluid from the pleural cavity. This position can compromise the respiratory status of the patient and is therefore not suitable for a thoracentesis.
Choice B rationale
The Trendelenburg position, where the head is lower than the feet, can increase intracranial pressure and is not suitable for thoracentesis. This position does not allow for the optimal access to the pleural space needed for the procedure.
Choice C rationale
Sitting upright while leaning forward over pillows is the ideal position for a thoracentesis. This position allows the fluid to accumulate at the base of the pleural cavity and provides easy access for the procedure. It also facilitates better breathing and reduces the risk of injury to the diaphragm and other internal structures.
Choice D rationale
Lying prone with arms extended away from the body does not provide adequate access to the pleural space for thoracentesis. This position also makes it difficult to manage and monitor the patient's respiratory status during the procedure. .
Correct Answer is A
Explanation
Choice A rationale
Installing grab bars in the shower assists with balance and prevents falls. Grab bars provide stability and support, which is crucial for clients who have had a CVA and may have impaired balance and coordination.
Choice B rationale
Placing a towel in the shower to prevent slipping is not recommended as it can shift and cause more risk. Anti-slip mats or adhesive strips are better options for preventing slips.
Choice C rationale
Hiring a home care aide to perform all ADLs may promote dependency and reduce the client's independence. Encouraging the use of assistive devices and adaptive techniques helps the client regain as much independence as possible.
Choice D rationale
The statement "You will not become fatigued when you use assistive devices" is incorrect. Clients may still experience fatigue, even with assistive devices. It's important to balance activity and rest to prevent overexertion.
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