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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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

If 500 mL of fluid is removed during thoracentesis, the nurse should notify the provider. Removing large volumes of fluid can cause re-expansion pulmonary edema.

Choice B rationale

A clear chest x-ray is an expected finding after thoracentesis.

Choice C rationale

PCO2 is a measure of carbon dioxide levels in the blood. It is not directly related to thoracentesis.

Choice D rationale

Hematocrit is a measure of the proportion of red blood cells in the blood. It is not directly related to thoracentesis.

A. Respiratory effort B. Heart rate C. Pain D. Blood pressure E. Mentation

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

Let’s analyze the data collection findings to determine if they are consistent with hypovolemic shock or pulmonary embolism:

Respiratory effort:
- Hypovolemic Shock: ✔
- Pulmonary Embolism: ✔
Heart rate:
- Hypovolemic Shock: ✔
- Pulmonary Embolism: ✔
Pain:
- Pulmonary Embolism: ✔
Blood pressure:
- Hypovolemic Shock: ✔
Mentation:
- Hypovolemic Shock: ✔
- Pulmonary Embolism: ✔

Each finding can support more than one condition, and there must be at least one selection in every column.

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A nurse is providing care for a patient who is in skeletal traction. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a patient following a thoracentesis.Which of the following findings should prompt the nurse to notify the provider?

Correct Answer is A

Explanation

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

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