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The nurse is caring for a client who has been treated with skeletal traction for two weeks. What are the priorities of care? (SELECT ALL THAT APPLY

Make certain that both feet are wedged tightly against the footboard

Provide pin care per institutional policy

Perform neurovascular checks

Assess for skin breakdown

Remove weights for 20 minutes every 2 hours

Answer and Explanation

Correct Answer : B,C,D

A. Feet should not be wedged tightly against the footboard, as it may cause pressure injuries.

B. Providing pin care prevents infection at the pin sites.

C. Neurovascular checks monitor for complications like compartment syndrome.

D. Assessing for skin breakdown is essential due to prolonged immobility.

E. Weights should not be removed unless prescribed, as it can disrupt the traction setup.

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Correct Answer is C

Explanation

A. Constipation is not a common side effect of aspirin.

B. Insomnia is not typically associated with aspirin.

C. Aspirin can cause gastrointestinal bleeding and increase bleeding risk due to its antiplatelet effects.

D. Blurred vision is not a common adverse effect of aspirin.

Correct Answer is ["1270"]

Explanation

Intake:

IV Fluids:

D5W: 150 ml/hr from 0700 to 1500 (8 hours) = 150 ml/hr * 8 hr = 1200 ml

Antibiotic: 50 ml every 4 hours, starting at 0800. So, it will be administered at 0800 and 1200 = 50 ml * 2 = 100 ml

Oral Intake:

Gelatin: 4 oz = 4 * 30 ml = 120 ml

Apple Juice: 10 oz = 10 * 30 ml = 300 ml

Water: 500 ml

Ice Chips: 16 oz (since ice chips are half liquid) = 16 * 30 ml / 2 = 240 ml

Total Intake: 1200 ml (D5W) + 100 ml (Antibiotic) + 120 ml (Gelatin) + 300 ml (Apple Juice) + 500 ml (Water) + 240 ml (Ice Chips) = 2460 ml

Output:

Urine Output:

0900: 100 ml

1100: 250 ml

1330: 290 ml

1445: 250 ml

Diarrhea Stool:

1200: 300 ml

Total Output: 100 ml + 250 ml + 290 ml + 250 ml + 300 ml = 1190 ml

Cumulative Fluid Balance:

Intake - Output: 2460 ml - 1190 ml = 1270 ml

So, the cumulative fluid balance for the 0700-1500 shift is +1270 ml.

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The nurse is caring for a client who has been treated with skeletal traction for two weeks. What are the priorities of care? (SELECT ALL THAT APPLY

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new prescription for aspirin to treat rheumatoid arthritis. The nurse should include to monitor for which of the following adverse effects of this medication?

Correct Answer is C

Explanation

Correct Answer is ["1270"]

Explanation

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