The nurse is aware that the maximum weight that can be applied with a skin traction is

Answer and Explanation

The Correct Answer is D

A. 35

35 pounds is too much for skin traction. That much weight can damage the skin and soft tissues.

B. 25

While closer, 25 pounds is above the recommended limit for skin traction. Excessive weight may lead to skin breakdown.

C. 15

Though this might be used occasionally, it’s still considered on the higher side and usually reserved for very short-term use.

D. 5

The recommended weight for skin traction is 5–7 pounds, because the skin and soft tissues cannot tolerate heavier loads.

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Correct Answer is ["B","E"]

Explanation

A. Move overbed tables away from the bed

Overbed tables should be kept within reach so clients don’t overextend or stand unsafely to access them.

B. Instruct the clients to use the call light

Reinforcing use of the call light promotes help-seeking before unsafe mobility attempts.

C. Perform client checks every 4 hr

High-risk clients should be checked more frequently, typically every hour or two, especially overnight.

D. Keep the clients' rooms dark

Poor lighting increases fall risk. A night light should be used.

E. Place a fall risk wristband on each of the clients

Fall risk wristbands alert staff and ensure precautions are taken consistently.

A. Mr. Milby states his pain level is a 0/10 B. Head of bed is elevated 45 degrees C. Mr. Milby complains of "tightness" of incision when CPM machine is at maximum flexion. D. all side rails on Mr. Milby's bed are down E. the knee dressing is loose and not adhering on all sides F. the machine is set to 45 degrees of flexion

Correct Answer is ["B","C","D","E"]

Explanation

A. Mr. Milby states his pain level is a 0/10

This indicates good pain control, which is expected and desired postoperatively.

B. Head of bed is elevated 45 degrees

Elevation this high may cause improper alignment and interfere with the machine’s function. Typically, HOB should be no more than 20-30 degrees during CPM use.

C. Mr. Milby complains of "tightness" of incision when CPM machine is at maximum flexion

This could indicate excessive tension on the wound or early signs of complications like swelling or dehiscence.

D. All side rails on Mr. Milby’s bed are down

This is a safety hazard. At least one or two side rails should be up during machine use to prevent falls.

E. The knee dressing is loose and not adhering on all sides

Loose dressings may indicate poor wound protection and risk for infection or wound exposure.

F. The machine is set to 45 degrees of flexion

This is per the physician’s order and indicates proper settings.

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The nurse is aware that the maximum weight that can be applied with a skin traction is

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Naxlex Comprehensive Predictor Exams

A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

Mr. Milby is a 69-year-old patient who underwent a total knee replacement 3 days ago. The orders fro the continuous passive motion (CPM) machine are to set it at 45 degrees of flexion and 0 degrees of extension for Mr. Milby. Select all the options that need to be reported to the responsible nurse.

Correct Answer is ["B","C","D","E"]

Explanation

The nurse explains that range of motion exercises are necessary so that movement improves venous circulation by:

A nurse is assisting a client with range-of-motion exercises of the shoulders. Which of the following terms should the nurse use when documenting the client raising his arm from his side to above his head?

A nurse is collecting data from a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

A nurse is collecting data from an older adult client who has had some bone density loss. The nurse observes excessive forward curvature of the thoracic spine. The nurse should document this finding using which of the following terminology?

A nurse is collecting data about a client's range of motion. Which of the following instructions should the nurse give to the client to observe hyperextension of the neck?

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client touching her chin to her chest?

A nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene?

A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?