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 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.
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