When providing care to a client in skeletal traction, what action would be included in the nurse's plan of care?

Provide cast care to bilateral lower extremities

Institute measures to prevent skin breakdown

Clean the pins every hour with peroxide to prevent infection

Place client on contact precautions

Maintain proper alignment and position of the traction

Answer and Explanation

The Correct Answer is E

Choice A reason: Providing cast care to bilateral lower extremities is not an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is not relevant to the type of traction. Skeletal traction involves the insertion of pins, wires, or screws into the bone, and does not require a cast. Cast care is more applicable to clients in plaster or fiberglass casts.

Choice B reason: Instituting measures to prevent skin breakdown is an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is a potential complication of prolonged immobilization and pressure. The nurse should inspect the skin regularly, change the bed linens frequently, use pressure-relieving devices, and encourage the client to shift positions as much as possible.

Choice C reason: Cleaning the pins every hour with peroxide to prevent infection is not an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is excessive and harmful. The nurse should follow the facility's protocol for pin site care, which usually involves cleaning the pins once or twice a day with a mild antiseptic solution, such as chlorhexidine or saline. Peroxide is not recommended, as it can damage the tissue and delay the healing.

Choice D reason: Placing the client on contact precautions is not an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is not indicated for this type of traction. Contact precautions are used for clients who have infections that can be transmitted by direct or indirect contact, such as MRSA, VRE, or C. difficile. Skeletal traction does not pose a high risk of infection, unless there is a pin site infection or osteomyelitis.

Choice E reason: Maintaining proper alignment and position of the traction is an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is essential for the effectiveness and safety of the traction. The nurse should ensure that the traction is applied correctly, that the weights are hanging freely, that the ropes are not twisted or frayed, and that the pulleys are not obstructed. The nurse should also avoid lifting or moving the weights, as it can alter the traction force and cause complications.

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Correct Answer is D

Explanation

Choice A reason: Calcitriol (Fortica) is not the medication that will have the least effect in increasing the client's bone mass, as it is a synthetic form of vitamin D that helps the body absorb calcium and phosphorus, which are essential for bone health. Calcitriol also regulates the bone remodeling and prevents the bone resorption.

Choice B reason: Calcium (Caltrate) with Vitamin D (Caltria) is not the medication that will have the least effect in increasing the client's bone mass, as it is a combination of calcium and vitamin D that works synergistically to enhance the bone density and strength. Calcium is the main mineral component of the bone, and vitamin D helps the body absorb calcium and phosphorus.

Choice C reason: Alendronate (Fosamax) is not the medication that will have the least effect in increasing the client's bone mass, as it is a bisphosphonate that inhibits the activity of osteoclasts, which are the cells that break down the bone. Alendronate reduces the bone loss and increases the bone mass, and it is used to treat and prevent osteoporosis.

Choice D reason: Calcium (Caltrate) without Vitamin D (Calcio) is the medication that will have the least effect in increasing the client's bone mass, as it is a calcium supplement that does not contain vitamin D, which is necessary for the calcium absorption and utilization. Calcium alone may not be sufficient to prevent or treat osteoporosis, and it may also cause side effects such as constipation, kidney stones, or hypercalcemia.

Choice E reason: None of the above is not a correct choice, as there is one option that matches the medication that will have the least effect in increasing the client's bone mass.

A. Green vegetables, whole wheat pasta, and poultry B. Low-fat milk, salmon with bones, and yogurt C. Fish, eggs, and potatoes D. Poultry, broccoli, and yellow vegetables E. Cheese, almonds, and tofu

Correct Answer is B

Explanation

Choice A reason: Green vegetables, whole wheat pasta, and poultry are not the best foods to include in the teaching plan when educating a client on increased calcium intake, as they are not rich sources of calcium. Green vegetables, such as kale, spinach, or broccoli, contain some calcium, but they also have oxalates, which can reduce the calcium absorption. Whole wheat pasta and poultry have very little calcium, and they are more sources of carbohydrates and protein, respectively.

Choice B reason: Low-fat milk, salmon with bones, and yogurt are the best foods to include in the teaching plan when educating a client on increased calcium intake, as they are high sources of calcium. Low-fat milk has about 300 mg of calcium per cup, salmon with bones has about 200 mg of calcium per 3 ounces, and yogurt has about 450 mg of calcium per cup. These foods also provide other nutrients, such as protein, vitamin D, and omega-3 fatty acids, which are beneficial for bone health.

Choice C reason: Fish, eggs, and potatoes are not the best foods to include in the teaching plan when educating a client on increased calcium intake, as they are not rich sources of calcium. Fish, such as tuna, cod, or halibut, have some calcium, but only if they are eaten with bones, which is not common. Eggs have about 25 mg of calcium per egg, which is very low. Potatoes have about 20 mg of calcium per medium potato, which is also very low.

Choice D reason: Poultry, broccoli, and yellow vegetables are not the best foods to include in the teaching plan when educating a client on increased calcium intake, as they are not rich sources of calcium. Poultry, such as chicken, turkey, or duck, have very little calcium, and they are more sources of protein and iron. Broccoli has about 40 mg of calcium per cup, which is low. Yellow vegetables, such as carrots, squash, or corn, have very little or no calcium, and they are more sources of vitamin A and fiber.

Choice E reason: Cheese, almonds, and tofu are not the best foods to include in the teaching plan when educating a client on increased calcium intake, as they are not suitable for everyone. Cheese has about 200 mg of calcium per ounce, but it is also high in fat, sodium, and calories, which may not be good for clients with high blood pressure, high cholesterol, or obesity. Almonds have about 75 mg of calcium per ounce, but they are also high in calories, and they may cause allergic reactions in some people. Tofu has about 250 mg of calcium per half cup, but it is also high in phytoestrogens, which may interfere with hormone levels in some people.

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When providing care to a client in skeletal traction, what action would be included in the nurse's plan of care?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

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