106 A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

Assess the pin sites for signs of infection.

Administer pain medication at designated intervals around the clock.

Assess the pulses proximal to the fracture site.

Remove traction every shift and provide skin care.

Answer and Explanation

The Correct Answer is A

A.   Assessing the pin sites for signs of infection is essential in clients with skeletal traction to detect any early signs of infection, such as redness, swelling, warmth, or purulent drainage. Prompt identification and management of pin site infections can prevent complications.
B.   Administering pain medication at designated intervals around the clock helps to ensure adequate pain control and comfort for the client. However, this intervention alone does not specifically address the care needs related to skeletal traction.
C.   Assessing the pulses proximal to the fracture site is important for monitoring circulation and detecting any signs of impaired perfusion. However, this assessment is not directly related to the care of skeletal traction itself.
D.   Removing traction every shift is not indicated unless there is a specific reason to do so as ordered by the healthcare provider. Continuous traction is often necessary for proper alignment and stabilization of the fracture. Additionally, providing skin care is important to prevent skin breakdown around the traction device, but removing traction every shift is not part of routine care.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Uremic Encephalopathy: The client has chronic kidney disease and elevated blood urea nitrogen (BUN) levels, indicating impaired kidney function. Symptoms such as feeling tired, fever, and possibly altered mental status can be associated with uremic encephalopathy, a condition that arises from the accumulation of toxins in the blood due to kidney failure.

Fluid Volume Overload: The client has elevated blood pressure (140/86 mm Hg), an irregular and elevated heart rate (117 beats/minute), and respiratory rate (36 breaths/minute), which can be signs of fluid volume overload. Additionally, the slight bibasilar infiltrates observed in the chest X-ray suggest potential fluid accumulation in the lungs.

A. Increase fluid intake to 3,000 mL/daily. B. Provide frequent rest periods. C. Administer O2 at 5 L/minute per nasal cannula. D. Maintain the client in a semi-Fowler's position.

Correct Answer is A

Explanation

A. Increasing fluid intake helps thin pulmonary secretions, making them easier to expectorate and is most directly related to clearing the airway.
B. Providing frequent rest periods is important but does not directly clear the airway.

C. Administering O2 addresses hypoxia but does not clear secretions.

D. Semi-Fowler's position helps with breathing but does not specifically address thick secretions.

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106 A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits After completing the initial assessment, the nurse has reviewed the 0930 laboratory results of blood specimens obtained in the outpatient clinic. Drag from Word Choices to complete the sentence. The nurse determines that the findings are reflective of and

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

The nurse is developing the plan of care for a client with pneumonia and includes the nursing problem of Ineffective airway clearance related to thick pulmonary secretions. Which intervention is most important for the nurse to include in the client's plan of care?

Correct Answer is A

Explanation

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