The nurse is assigned to care for a client in traction. The nurse creates a plan of a care for the client and would include which action in the pian?
Remove the traction when the client wants to ambulate
Provide pin site care for skin traction.
Check the weights to ensure that they are hanging freely
Adjust the amount of weight depending on the clients preference
The Correct Answer is C
A) Remove the traction when the client wants to ambulate:
Traction is a therapeutic treatment used to immobilize bones, joints, or soft tissues, often after fractures or orthopedic procedures. Removing traction to allow ambulation is not appropriate unless directed by a healthcare provider. Traction must be maintained to ensure proper alignment and healing of the affected body part. Premature removal can cause complications such as malalignment, delayed healing, or further injury.
B) Provide pin site care for skin traction:
Pin site care is required for skeletal traction, not skin traction. Skin traction uses adhesive strips or other external devices to apply force to the body, and no pins are involved. Skeletal traction, on the other hand, uses pins, screws, or wires that are inserted directly into the bone. It’s important to provide proper pin site care to prevent infection in skeletal traction, but this is not relevant to skin traction, which doesn’t involve direct penetration of the skin.
C) Check the weights to ensure that they are hanging freely:
It is essential to check that the weights in traction are hanging freely and not in contact with the floor or any other surface. Weights should be unobstructed to provide continuous, even force that maintains the proper alignment of the injured body part. Any obstruction or improper positioning of the weights can compromise the effectiveness of the traction and delay healing.
D) Adjust the amount of weight depending on the client’s preference:
The amount of weight used in traction is determined by the healthcare provider based on the specific injury or condition being treated. Adjusting the weight based on the client's preference could lead to inappropriate tension, worsening the injury or hindering the healing process. The nurse should not adjust the weight without a physician’s order, as it is critical to follow the prescribed treatment plan for optimal healing and safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
The correct answers are:
A. You may start taking warfarin while still on heparin when you are getting ready to be discharged home.
- Warfarin takes several days to reach therapeutic levels, so patients often overlap with heparin until the INR (International Normalized Ratio) reaches the target range (typically 2.0-3.0 for most conditions).
C. Use a soft-bristled toothbrush and avoid brushing too aggressively.
- Warfarin increases the risk of bleeding, so using a soft toothbrush helps prevent gum bleeding.
D. You should replace straight razors with an electric shaver to avoid cuts.
- Since warfarin thins the blood, small cuts can lead to excessive bleeding. An electric shaver reduces the risk of accidental cuts.
B. You will need to have your aPTT monitored frequently while on Warfarin. (Incorrect)
- Warfarin is monitored using INR and PT (Prothrombin Time), not aPTT.
- aPTT (Activated Partial Thromboplastin Time) is used to monitor heparin therapy, not warfarin.
E. Increase foods high in vitamin K like dark green leafy vegetables while taking Warfarin. (Incorrect)
- Vitamin K counteracts warfarin's effects, so patients should keep their vitamin K intake consistent rather than increasing it.
Correct Answer is D
Explanation
A. A patient with hypertension:
Valproic acid is not contraindicated in patients with hypertension. While it is important to monitor for potential side effects, including those that may affect the liver or blood pressure, hypertension alone does not directly impact the safety or efficacy of valproic acid. Therefore, it is generally considered safe to prescribe in patients with well-controlled hypertension.
B. A patient with diabetes:
Valproic acid is also not contraindicated in patients with diabetes. While it is important to monitor blood glucose levels, as anticonvulsants can sometimes affect metabolic processes, there is no absolute contraindication for valproic acid in diabetic patients. However, appropriate monitoring of blood sugar levels would be necessary to adjust any diabetic treatment as needed.
C. A patient with asthma:
There is no direct contraindication to using valproic acid in a patient with asthma. While asthma medications and their interactions should always be considered, valproic acid does not typically exacerbate asthma symptoms. The prescription would be based on the clinical need for seizure management and monitored for any potential respiratory side effects.
D. A pregnant patient:
Valproic acid is contraindicated in pregnancy due to its high risk of causing fetal harm. It has been associated with an increased risk of birth defects, including neural tube defects, and other complications such as developmental delays. The U.S. FDA classifies valproic acid as a Category D drug for pregnancy, indicating that it should only be used when the potential benefits outweigh the risks. Thus, it should be avoided in pregnant patients unless no safer alternatives are available.
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