A nurse is providing care for a patient who is in skeletal traction. Which action should the nurse take?
Unscrew the pins to clean the pin sites.
Loosen the rope knots holding the weights for 30 minutes if the patient reports pain.
Ensure that at least 4.5 kg (10 lb) of weight is applied to the patient’s traction.
Remove the weights while turning the patient in bed.
The Correct Answer is C
Choice A rationale
Unscrewing the pins to clean the pin sites is not recommended. This could lead to infection and disrupt the traction.
Choice B rationale
Loosening the rope knots holding the weights for 30 minutes if the patient reports pain is not recommended. The weights provide the necessary force to align and immobilize the body part and should not be removed.
Choice C rationale
Ensuring that at least 4.5 kg (10 lb) of weight is applied to the patient’s traction is a correct action. The amount of weight applied must be sufficient to provide the necessary force for alignment.
Choice D rationale
Removing the weights while turning the patient in bed is not recommended. The weights must remain in place to maintain the therapeutic effect of the traction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Bathing in a tub until the catheter is removed is not recommended after a transurethral resection of the prostate (TURP). This could increase the risk of infection.
Choice B rationale
Taking ibuprofen for discomfort is not typically recommended after TURP. Ibuprofen can increase the risk of bleeding.
Choice C rationale
Waiting 6 weeks before resuming sexual intercourse is a standard recommendation after TURP. This allows the body time to heal.
Choice D rationale
Driving after 1 week is not typically recommended after TURP. Patients are usually advised to avoid driving until they are free of pain and can move quickly and safely.
Correct Answer is C
Explanation
Choice A rationale
Discontinuing the nasogastric tube is not the best action to take at this time. The nasogastric tube may be necessary for decompression of the stomach or administration of medications and should not be removed without a specific order from the healthcare provider.
Choice B rationale
Providing the client with ice chips is not the most appropriate action. The client is kept NPO (nothing by mouth) before surgery to prevent aspiration during anesthesia. Therefore, giving the client ice chips could increase the risk of aspiration.
Choice C rationale
Starting the prescribed antibiotic is the correct action. Cefazolin is an antibiotic that is often given before surgery to prevent postoperative infections. Administering this medication as ordered can help to ensure that the client is adequately prepared for surgery.
Choice D rationale
While reinforcing preoperative teaching is an important part of nursing care, it is not the most immediate action that should be taken in this situation. The client’s physical preparation for surgery, including the administration of prescribed medications, should be prioritized.
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