A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

The client develops a life-threatening situation.

The client needs to have an x-ray of the femur performed.

The client complains of pain.

The client has to be repositioned in the bed.

Answer and Explanation

The Correct Answer is A

A. In the event of a life-threatening situation, the immediate priority is to address the situation to stabilize the client's condition. If removing the weights from the traction device is necessary to manage the life-threatening situation then the nurse may remove the weights as part of the overall management of the client's care.

B. It's generally not necessary to remove the weights from the traction device for an x-ray of the femur. Instead, the x-ray can typically be performed with the weights in place.

C. Pain management is important for clients in traction, but removing the weights is not the initial action for addressing pain. The nurse should assess the cause of the pain and intervene appropriately.

D. Repositioning the client in the bed may be necessary for comfort, preventing pressure ulcers, or facilitating care activities. When repositioning the client, the nurse should ensure that the traction setup remains intact and that the weights are properly secured.

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Correct Answer is B

Explanation

B. Assessing the client's pain level is crucial, especially before physical therapy, as pain can affect participation and compliance with therapy. If the client is experiencing pain, appropriate pain management measures should be implemented before PT to optimize participation and comfort.

A. The nurse should educate the client on proper body mechanics and positions to avoid during physical therapy to promote safe movement and prevent complications. However, this is not a priority.

C. While morning care is important for maintaining hygiene and comfort, it may not be the priority at this specific time, especially if the client is scheduled for physical therapy soon.

D. Encouraging full weight bearing immediately postoperative may not be appropriate, as the surgical site needs time to heal and regain strength.

A. "I will limit my fluid intake to 1 liter per day." B. "I will limit my alcohol intake." C. "I will take one aspirin every day." D. "I will closely follow a high-purine diet."

Correct Answer is B

Explanation

B. Alcohol consumption, especially beer and spirits, is associated with an increased risk of gout attacks as it can elevate uric acid levels in the body. Limiting alcohol intake can help prevent gout attacks.

A. While adequate hydration is important for overall health, limiting fluid intake to 1 liter per day may not be appropriate, especially considering that hydration can help prevent gout attacks.

C. While aspirin is commonly used for pain relief, it is not typically recommended for gout management.

D. High-purine foods such as red meat, organ meats, and certain seafood can exacerbate gout symptoms by increasing uric acid levels in the body. Therefore, closely following a high-purine diet would likely worsen gout symptoms rather than improve them.

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A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

Nursing Test Bank

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