A nurse is caring for a pediatric patient in skeletal traction for a femur fracture. Which nursing action is the highest priority to prevent complications associated with skeletal traction?
Ensure the weights hang freely and do not touch the floor to maintain proper traction force.
Remove the traction weights every 6 hours to prevent skin breakdown,
Limit monitoring of pin sites to once every 24 hours to reduce patient discomfort.
Place the rope knot in contact with the pulley to stabilize the traction system.
The Correct Answer is A
A. Ensure the weights hang freely and do not touch the floor to maintain proper traction force is correct. Proper skeletal traction depends on continuous, consistent force applied through the weights. If the weights touch the floor or are obstructed, the traction is disrupted, which can result in malalignment, delayed healing, increased pain, or neurovascular compromise. Maintaining correct traction mechanics is the highest priority to prevent serious complications.
B. Remove the traction weights every 6 hours is incorrect because weights should never be removed unless prescribed. Interrupting traction can cause muscle spasm, malalignment, or delayed fracture healing. Skin breakdown is addressed through regular skin care and positioning, not by removing weights.
C. Limit monitoring of pin sites to once every 24 hours is incorrect because pin sites require frequent assessment (at least every 4–8 hours) for signs of infection, inflammation, or loosening. Infrequent monitoring increases the risk of osteomyelitis or local infection.
D. Place the rope knot in contact with the pulley is incorrect because this would interfere with the smooth functioning of the traction system. The rope must move freely through the pulley to maintain proper tension and alignment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Smoking and age over 35 years is correct because women over 35 who smoke have a significantly increased risk of cardiovascular events, such as myocardial infarction and stroke, when taking estrogen-containing oral contraceptives.
B. Migraine headaches with aura is correct because migraine with aura increases the risk of stroke, and estrogen-containing oral contraceptives can further increase thromboembolic and cerebrovascular risk.
C. History of blood clots (deep vein thrombosis) is correct because estrogen-containing contraceptives increase the risk of venous thromboembolism. Women with a history of DVT or pulmonary embolism should avoid combined oral contraceptives.
D. Family history of breast cancer is incorrect because a family history alone is not an absolute contraindication for oral contraceptives. While caution may be advised, combined oral contraceptives are not contraindicated solely based on family history.
E. Controlled hypertension is incorrect because mild, well-controlled hypertension is not an absolute contraindication. The risk increases in women with uncontrolled or severe hypertension, making oral contraceptives unsafe in that context.
Correct Answer is D
Explanation
A. Non-Hodgkin's lymphoma is more commonly associated with painless, enlarged lymph nodes than Hodgkin's lymphoma is incorrect because both HL and NHL can present with painless lymphadenopathy, so this is not a distinguishing feature.
B. Hodgkin's lymphoma presents with a more aggressive course than Non-Hodgkin's lymphoma is incorrect because, in children, Non-Hodgkin’s lymphoma generally has a more aggressive and rapid course compared with Hodgkin’s lymphoma, which usually progresses more slowly.
C. Non-Hodgkin's lymphoma typically involves the Reed-Sternberg cells is incorrect because Reed-Sternberg cells are characteristic of Hodgkin’s lymphoma, not Non-Hodgkin’s lymphoma. Their presence is a key diagnostic feature of HL.
D. Hodgkin's lymphoma usually has a more predictable and localized spread than Non-Hodgkin's lymphoma is correct. Hodgkin’s lymphoma tends to spread in a contiguous, orderly fashion from one lymph node group to another, often starting in cervical or supraclavicular nodes. Non-Hodgkin’s lymphoma, in contrast, tends to spread more diffusely and rapidly, involving extranodal sites such as the gastrointestinal tract, mediastinum, and bone marrow.
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