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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Reconciling medication dosages is important but comes after verifying the accuracy of the prescriptions.
B. Comparing admission prescriptions with the client's previous medication list ensures continuity of care and prevents omissions or duplications.
C. Determining generic versus brand name medications can be addressed later after ensuring medication accuracy.
D. Client teaching is important but should follow the verification of the client's current medications.
Correct Answer is B
Explanation
A. Not taking diabetes medication when feeling sick could lead to uncontrolled blood sugar levels.
B. Having rapid-acting glucose readily available indicates understanding of the importance of managing hypoglycemic episodes.
C. While important, obtaining an A1C test annually is not directly related to managing acute hyperglycemia.
D. Using salt, herbs, and spices does not directly address blood glucose control.
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