Which nursing intervention is appropriate for a client with skeletal traction?

Pin site care

Five-pound weight lifting restriction

Prone positioning

Intermitent weights

Answer and Explanation

The Correct Answer is A

Choice A reason: Pin site care is essential for a client with skeletal traction to prevent infection and ensure proper healing.

Choice B reason: A five-pound weight lifting restriction is not related to the care of a client with skeletal traction.

Choice C reason: Prone positioning is not typically recommended for clients with skeletal traction as it may interfere with the traction setup.

Choice D reason: Intermitent weights are not a standard intervention for skeletal traction, which requires consistent and controlled application of force.

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Correct Answer is C

Explanation

Choice A reason: An RBC count of 4,500,000/mL is within the normal range and would not typically cause symptoms of anemia.

Choice B reason: Normal RBC indices do not indicate anemia and would not explain the symptoms.

Choice C reason: A hemoglobin level of 8.2 g/dL is below the normal range and would be consistent with symptoms of anemia such as fatigue and palpitations.

Choice D reason: A hematocrit of 38% is within the normal range for adult males and would not typically be associated with anemia symptoms.

A. Stable ECG rhythm B. Ability to verbalize causes and eﬀects of CHD/CAD C. Adequate relief of pain D. Compliance with prescribed bedrest

Correct Answer is C

Explanation

Choice A reason : While maintaining a stable ECG rhythm is important, it is not the highest priority. The primary concern is to address life-threatening complications.

Choice B reason : Educating the patient about the causes and eﬀects of coronary heart disease (CHD) or coronary artery disease (CAD) is important for long-term management but is not the immediate priority during acute care.

Choice C reason : Adequate relief of pain is the highest priority in the care of a patient with AMI. Pain is an indicator of ongoing ischemia and can increase the workload of the heart, thereby worsening the condition.

Choice D reason (AMI): While bedrest is part of the care plan, it is not the highest priority compared to pain relief, which has direct implications on the patient's immediate physiological status.

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Which nursing intervention is appropriate for a client with skeletal traction?

Nursing Test Bank

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