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 C

Explanation

A) "I will notify my doctor before taking any other medications:"
Phenytoin interacts with many medications, both prescription and over-the-counter. It is crucial for the client to inform their doctor before starting any new medications, including herbal supplements, as phenytoin may have significant drug interactions that could alter its effectiveness or increase the risk of side effects.

B) "I should talk to my doctor about other methods of contraception in addition to my current oral contraceptives:"
Phenytoin can decrease the effectiveness of oral contraceptives, leading to an increased risk of unintended pregnancy. It is important for clients to discuss alternative or additional methods of contraception, such as non-hormonal methods or alternative hormonal birth control, with their healthcare provider to prevent pregnancy while taking phenytoin.

C) "I'll be glad when I can stop taking this medicine after my seizures are controlled:"
Phenytoin is typically a lifelong medication for managing seizures, even if the seizures are well-controlled. Stopping the medication without a doctor's approval can lead to seizure recurrence. Seizure control does not always mean stopping medication, and clients need to understand the importance of continuing the prescribed treatment regimen, even after achieving stability.

D) "I have made an appointment to see my dentist next week:"
Phenytoin can cause gingival hyperplasia, which increases the need for regular dental checkups. It is recommended that clients taking phenytoin see a dentist regularly to manage this potential side effect and maintain oral health.

A. Though the condition can be inconvenient, there are no long-term negative effects of GERD B. You should avoid lying flat on your back for 2-3 hours after eating. C. If you use antacids they should be separated from other oral medications by several hours D. You should avoid spicy, fatty, and acidic foods as much as possible as they can trigger reflux.

Correct Answer is A

Explanation

A) Though the condition can be inconvenient, there are no long-term negative effects of GERD: This is the incorrect statement. GERD, if left untreated, can lead to significant long-term complications, such as esophagitis, strictures, Barrett's esophagus (a precancerous condition), and an increased risk of esophageal cancer. Therefore, it’s critical to manage GERD effectively to prevent these adverse outcomes.

B) You should avoid lying flat on your back for 2-3 hours after eating: advice. Lying flat after eating can increase the likelihood of reflux, as it allows stomach acid to flow back into the esophagus more easily due to gravity. Staying upright for at least 2-3 hours after meals helps prevent acid reflux.

C) If you use antacids they should be separated from other oral medications by several hours: . Antacids can interfere with the absorption of other oral medications by altering the stomach’s pH. It’s recommended to take antacids at least 1-2 hours apart from other medications to avoid reducing their effectiveness.

D) You should avoid spicy, fatty, and acidic foods as much as possible as they can trigger reflux: This is also correct. Certain foods, like spicy, fatty, and acidic items, can relax the lower esophageal sphincter and increase gastric acid production, both of which can exacerbate GERD symptoms. Avoiding or limiting these foods can help manage the condition more effectively.

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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

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin, which of following statements by the client indicates a need for further teaching?

Correct Answer is C

Explanation

The nurse is providing education to a client newly diagnosed gastroesophageal reflux (GERD). Which of the following would be an incorrect statement about this condition?

Correct Answer is A

Explanation

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