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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Have the client lay prone for 30 minutes. 3-4 times a day:
This statement is correct. Lying prone (on the stomach) for 30 minutes several times a day helps to prevent hip flexion contractures, which are common complications after an above-the-knee amputation. By lying prone, the residual limb is stretched and the hip joint is kept in an extended position, which helps maintain proper alignment and reduces the risk of contractures. This is a key part of postoperative care to promote optimal positioning and rehabilitation.

B. Continue using the limb prosthesis even if the skin appears irritated:
This statement is incorrect. If the skin becomes irritated or damaged, the prosthesis should not be used until the skin has healed. Continued use of the prosthesis in the presence of skin irritation can cause further damage, leading to ulcers or infections. It is essential to regularly check the residual limb for irritation, redness, or sores and adjust the prosthesis as needed. If irritation is present, the prosthesis should be removed, and appropriate skin care should be provided.

C. Withhold medication for phantom limb pain as it isn't real pain:
This statement is incorrect. Phantom limb pain is real and a common experience for individuals after an amputation. It occurs when the brain perceives pain sensations in the area where the limb used to be, even though the limb is no longer there. Phantom limb pain is often treated with pain medications, including analgesics, anticonvulsants, or antidepressants, and should not be withheld. Proper management of phantom limb pain is important for the client's comfort and overall well-being.

D. Keep the residual limb elevated to achieve as close to 90-degree hip flexion as possible:
This statement is incorrect. While it is important to elevate the residual limb after surgery to reduce swelling, it should not be elevated to the point where the hip joint is flexed to 90 degrees. Elevating the limb too much or for prolonged periods can increase the risk of developing a hip flexion contracture, which would impair mobility. The residual limb should be elevated slightly, but the hip joint should not be excessively flexed. Ideally, the limb should be positioned in a neutral or extended position when elevated.

A. Pernicious anemia B. Blood loss anemia C. Sickle cell anemia D. Aplastic anemia

Correct Answer is B

Explanation

A. Pernicious anemia:
Pernicious anemia is primarily caused by a deficiency in vitamin B12, often due to a lack of intrinsic factor needed for absorption in the gut. It typically presents with symptoms like weakness, fatigue, and neurological manifestations such as numbness or tingling. However, the client’s presentation does not suggest a vitamin B12 deficiency or neurological signs. Additionally, pernicious anemia is not typically associated with heavy menstrual periods,
which are more indicative of blood loss anemia.

B. Blood loss anemia:
Blood loss anemia is the most likely diagnosis in this case, especially in the context of heavy menstrual periods, which can cause significant blood loss over time. The client’s hemoglobin level of 6.9 g/dL indicates severe anemia, which is consistent with the cumulative effects of chronic blood loss. This type of anemia results from a decrease in red blood cell count due to bleeding, which can lead to symptoms like weakness, fatigue, and pallor.

C. Sickle cell anemia:
Sickle cell anemia is a genetic condition characterized by abnormally shaped red blood cells, which can lead to hemolysis and episodes of pain. While it can cause symptoms like fatigue and weakness, sickle cell anemia typically presents earlier in life and is more associated with episodes of severe pain and organ damage. Additionally, the patient’s history does not mention episodes of pain or other hallmark signs of sickle cell disease, such as swelling in the hands or feet or recurrent infections.

D. Aplastic anemia:
Aplastic anemia occurs when the bone marrow fails to produce enough blood cells, including red blood cells, white blood cells, and platelets. It presents with symptoms like weakness, fatigue, frequent infections, and bruising. Although this client does have anemia, the lack of additional signs (such as petechiae, infections, or bleeding) makes this diagnosis less likely. Aplastic anemia is also usually diagnosed with bone marrow biopsy, which is not suggested by this client's presentation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following interventions should the nurse include when caring for a client who is returning from surgery for an above-the-knee amputation?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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