When caring for a patient in skeletal traction, the nurse should complete which 4 interventions?
Perform neurovascular assessment on the affected extremity.
Ensure that the weights lay flat on the ground.
Observe pin sites for signs of infection.
Assess skin for signs of breakdown.
Apply boot directly to the skin.
Provide pin site care.
Correct Answer : A,C,D,F
Choice A rationale
Performing neurovascular assessments on the affected extremity helps identify potential complications such as ischemia or nerve damage. This includes checking circulation, sensation, and movement regularly to ensure proper function and prevent permanent injury.
Choice B rationale
Skeletal traction relies on the tension created by weights hanging freely to maintain proper alignment of the bone. If weights lay flat on the ground, the traction effect is lost, undermining the therapeutic purpose of the intervention.
Choice C rationale
Observing pin sites for signs of infection is crucial in preventing complications like osteomyelitis. Regular monitoring ensures early detection and management of redness, swelling, or discharge, which can compromise treatment outcomes.
Choice D rationale
Assessing skin for signs of breakdown is essential in immobile patients receiving skeletal traction. Prolonged pressure and reduced mobility increase the risk of pressure ulcers, necessitating vigilant skin checks and preventive measures.
Choice E rationale
Applying a boot directly to the skin is not appropriate in skeletal traction. Devices must be used correctly and securely without creating additional pressure points or compromising the treatment's effectiveness.
Choice F rationale
Providing pin site care prevents infections and maintains the integrity of the pin and surrounding tissue. This involves cleaning the area and using antiseptics, which are standard practices in skeletal traction care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Staying with the patient and rechecking blood glucose delays immediate corrective action required for severe hypoglycemia (40 mg/dL). While safety is important, prompt treatment with glucose is the priority to prevent further complications.
Choice B rationale
Following the hypoglycemia protocol ensures immediate glucose administration, either orally, intravenously, or intramuscularly, to stabilize the patient. This is critical as glucose levels below 40 mg/dL require urgent intervention to prevent neuronal damage or coma.
Choice C rationale
Monitoring and rechecking glucose after treating is essential but not sufficient as the first action. Hypoglycemia this severe needs immediate treatment before monitoring, ensuring prompt glucose replacement to prevent worsening symptoms.
Choice D rationale
Notifying the physician without treating the hypoglycemia risks unnecessary delays. Immediate action, such as administering glucose per protocol, is vital in this emergency scenario for patient safety.
Correct Answer is C
Explanation
Choice A rationale
Low urine output could be due to dehydration, medication effects, or stress. While it warrants further assessment, it is not typically associated with immediate life-threatening complications in the context of PUD.
Choice B rationale
Vomiting after a meal can occur in PUD due to delayed gastric emptying or irritation. However, it does not immediately indicate a complication requiring urgent follow-up unless accompanied by other symptoms such as severe pain or hematemesis.
Choice C rationale
Blood in the stool may indicate gastrointestinal bleeding, a serious complication of PUD. This finding requires immediate evaluation to determine the source and extent of bleeding, as it can lead to hypovolemic shock if untreated.
Choice D rationale
Abdominal discomfort is common in PUD due to gastric irritation or acid-related issues. While it requires management, it does not typically signal an urgent complication unless associated with other alarming symptoms.
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