The nurse assesses a client with rheumatoid arthritis (RA) and Sjögren syndrome. What assessment would be most important for this client?

Choice A reason: Removing traction during repositioning disrupts the continuous pull needed to maintain bone alignment in fractures. This could lead to misalignment, delayed healing, or increased pain, as traction counteracts muscle spasms and stabilizes the fracture site.
Choice B reason: While skin assessment during a bed bath is important to detect pressure injuries, it is a general nursing responsibility, not specific to traction care. Traction-specific teaching focuses on maintaining the system’s integrity, such as ensuring proper weight function, over general hygiene tasks.
Choice C reason: Using alcohol wipes for pin care in skeletal traction is inappropriate, as it may not adequately prevent infection. Pin sites require sterile technique with solutions like chlorhexidine to minimize osteomyelitis risk, making this an incorrect teaching point.
Choice D reason: In traction, weights must hang freely to maintain consistent force for bone alignment and fracture stabilization. Obstructed weights reduce traction effectiveness, potentially causing misalignment, delayed healing, or increased pain, making this a critical teaching point for safe traction care.

Choice A reason: The maximum daily dose of acetaminophen for adults is typically 4000 mg to avoid hepatotoxicity. A statement indicating 5000 mg suggests a misunderstanding, as exceeding 4000 mg increases the risk of liver damage due to the accumulation of toxic metabolites like N-acetyl-p-benzoquinone imine, which depletes glutathione.
Choice B reason: Regular liver function tests are recommended for clients on long-term acetaminophen to monitor for hepatotoxicity, as the drug is metabolized by the liver. This statement shows correct understanding, as it acknowledges the need to assess liver enzymes like ALT and AST for potential damage.
Choice C reason: Checking other medications for acetaminophen content is crucial to prevent unintentional overdose, which can lead to acute liver failure. This statement reflects proper understanding, as combination drugs (e.g., cold remedies) often contain acetaminophen, contributing to cumulative toxicity if not monitored.
Choice D reason: Using topical patches or creams for osteoarthritis pain is a valid adjunctive therapy. These deliver localized relief (e.g., NSAIDs or capsaicin) without systemic effects, complementing acetaminophen’s action. This statement indicates correct understanding of multimodal pain management strategies.