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

Explanation

A. Use metal clips to secure the wrap:

While metal clips are commonly provided with elastic bandages, they can easily become dislodged and may cause injury. Tape or self-adhesive wraps are often safer and more secure.

B. Adjust the pressure or tension as needed:

This allows for proper circulation and comfort. Bandages should be snug but not tight, and pressure may need to be adjusted for swelling or anatomical differences.

C. Overlap turns of the bandage equally:

This is a correct technique but not the most critical factor for effectiveness and safety. Equal overlapping helps provide uniform pressure, but adjusting tension as needed is more essential.

D. Face the patient and wrap from proximal to distal:

Wrapping should always go from distal to proximal to promote venous return and reduce edema. Wrapping proximal to distal is incorrect and can impair circulation.

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 applying an elasticized bandage to the leg of a patient. To perform this procedure correctly, the nurse should:

Correct Answer is B

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

A patient who fractured a leg several weeks ago is scheduled for cast removal after he returns home. The nurse should explain to the patient to expect the skin underneath the cast to appear:

A patient has just had a leg cast applied with plaster of Paris. The nurse can best reduce the incidence of edema by:

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 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 stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip?

A nurse performing a head to toe neurovascular check on a patient in a long leg cast notes an indication of altered perfusion as evidenced by:

A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include?

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?