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 A

Explanation

A. Reviewing the white blood cell (WBC) count is important because purulent drainage suggests infection, and an elevated WBC count may indicate an inflammatory response to infection.

B. Hematocrit is an important parameter to monitor but may not directly indicate the presence of infection associated with purulent drainage in a burn wound.

C. Blood pH level is an important parameter to monitor but may not directly indicate the presence of infection associated with purulent drainage in a burn wound.

D. Platelet count is an important parameter to monitor but may not directly indicate the presence of infection associated with purulent drainage in a burn wound.

A. Wear braces on both wrists during the night. B. Notify the healthcare provider as soon as possible. C. Elevate the hands on two pillows at night. D. Apply cold compresses for 30 minutes before bedtime.

Correct Answer is A

Explanation

A. Wearing braces on both wrists during the night can help maintain a neutral wrist position and alleviate pressure on the median nerve, reducing symptoms of carpal tunnel syndrome.

B. Notifying the healthcare provider may be necessary if symptoms worsen or if additional interventions are needed, but this is not the first-line intervention for managing symptoms at night.

C. Elevating the hands on two pillows at night may provide some relief, but it is not as effective as wearing wrist braces to maintain proper alignment and reduce pressure on the median nerve.

D. Applying cold compresses before bedtime may help reduce inflammation but is not specifically targeted at alleviating nighttime symptoms of carpal tunnel syndrome.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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