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 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. .

A. Instill a warm enema solution. B. Apply a cooling blanket. C. Administer meperidine IM. D. Ventilate the client with 50% oxygen.

Correct Answer is B

Explanation

Choice A rationale

Instilling a warm enema solution is not appropriate for treating malignant hyperthermia. The focus should be on cooling measures and medications.

Choice B rationale

Applying a cooling blanket is an appropriate action to help reduce the client's body temperature during malignant hyperthermia.

Choice C rationale

Administering meperidine IM is not indicated for malignant hyperthermia. The appropriate medications include dantrolene, cooling measures, and supportive care.

Choice D rationale

Ventilating the client with 100% oxygen, not 50%, is the appropriate action to ensure adequate oxygenation during malignant hyperthermia.

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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?