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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 A

Explanation

A. The first priority is to assess whether the numbness and tingling in the left leg are new or a preexisting symptom. This helps identify if there are complications like nerve injury or issues with the surgical site.

B. While documenting the findings is important, it’s more critical to compare these new symptoms with preoperative findings to identify potential complications.

C. Drawing blood for serum calcium is not directly relevant to the immediate issue of nerve symptoms after a laminectomy.

D. Telling the client that the symptoms are normal could lead to delayed intervention if there is a more serious issue, like nerve damage or surgical complications.

A. Increase the pain level and need for medication. B. encourage the development of a flexion contracture. C. stop circulation to the extremity. D. cause possible skin breakdown.

Correct Answer is B

Explanation

A. While pain may increase if the knee is positioned improperly, the primary concern is the development of a contracture.

B. Placing a pillow under the knee after total knee replacement can promote a flexion contracture, which results in the inability to fully extend the knee. This is undesirable as it can limit mobility and function post-surgery.

C. The pillow does not stop circulation to the extremity directly.

D. A pillow under the knee is not typically associated with skin breakdown unless the client is immobile for extended periods, but the risk of contracture is a more immediate concern.

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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 assessing a client on the first post-operative day after a L3-4 laminectomy and diskectomy. The client now complains of numbness and tingling in the left leg. What is the nurse's first priority?

Correct Answer is A

Explanation

The nurse understands that the placement of a pillow under the knee of a client with a total knee replacement is contraindicated because it will:

Correct Answer is B

Explanation

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

The patient has been admitted to the med-surg unit with the diagnosis of sprained ankle. Which of the following interventions are important to implement for this patient? (SELECT ALL THAT APPLY).

A nurse is caring for a client with osteoarthritis. The nurse should expect which findings with this disease process?

A client is receiving IV fluids at 100 ml per hour. The nurse is told in report at 1200 that there are 500 ml left in the bag. At what time should the nurse expect to hang a new bag? Report the time in military time.

A client returns to the unit after undergoing a total hip replacement with a cemented prosthesis. Which order should the nurse anticipate regarding weight bearing status?

A client with traumatic injuries has a comminuted open fracture of the femur that has been placed in an external fixator. The nurse recognizes that compartment syndrome is associated with which clinical assessment finding?

The client has fibromyalgia and asks the nurse why this occurs. Which statement by the client, would show that the explanation was understood?

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