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 C
Explanation
Choice A rationale
Applying a warm pack is inappropriate for controlling active bleeding, as it can exacerbate blood flow to the site, worsening the hemorrhage rather than controlling it effectively.
Choice B rationale
Using a tourniquet above the bleeding site is a last-resort method typically reserved for life-threatening bleeding. It may cause complications such as nerve damage or ischemia, so other measures are prioritized first.
Choice C rationale
Direct pressure or sterile pressure dressing with elevation minimizes blood loss effectively by compressing the damaged vessels, promoting clot formation, and utilizing gravity to reduce the pressure at the wound site. It is the recommended first-line method.
Choice D rationale
Placing an ice pack on the bleeding site may reduce localized blood flow by inducing vasoconstriction but is less effective than direct pressure for stopping active hemorrhage. It is secondary to other control measures.
Correct Answer is A
Explanation
Choice A rationale
Contact isolation prevents the transmission of Clostridium difficile spores, a significant source of nosocomial infections. Private rooms reduce cross-contamination risks.
Choice B rationale
Antidiarrheal use is contraindicated in Clostridium difficile infection as it may worsen colitis by retaining toxins. Prompt stool elimination is vital.
Choice C rationale
Antibiotics are used to treat Clostridium difficile but educating the patient about antibiotic cessation is inappropriate as their use is essential for infection control.
Choice D rationale
Stool softeners are unnecessary since diarrhea is already present, and further softening may exacerbate fluid and electrolyte loss.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.