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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential condition: Retinopathy
Actions to take: Orient the client to the environment; Call for an ophthalmological exam
Parameters to monitor: Blood glucose; Visual acuity
Rationale:
Based on the patient data provided, the client is most likely experiencing retinopathy, particularly diabetic retinopathy, which is a common complication of diabetes and can lead to progressive vision loss. The elevated HBA1C level indicates poor blood glucose control, which can contribute to the worsening of this condition.
The nurse should call for an ophthalmological exam to confirm the diagnosis and assess the extent of retinal damage. Additionally, orienting the client to the environment is important to ensure safety due to the vision impairment. Monitoring the client's blood glucose levels is crucial for managing his diabetes and potentially stabilizing or improving the retinopathy.
Visual acuity should also be monitored to track any changes in vision and the effectiveness of interventions. It is essential to manage the underlying diabetes effectively to prevent further progression of retinopathy.
Correct Answer is A
Explanation
A. Palpitations and shortness of breath are symptoms of thyrotoxicosis, indicating excessive thyroid hormone levels, which could result from an overdose of levothyroxine sodium.
B. Bradycardia and constipation are more indicative of hypothyroidism, which would suggest the need for an increase in levothyroxine dosage rather than a decrease.
C. Muscle cramping and dry, flushed skin are symptoms of hypothyroidism, which would suggest inadequate thyroid hormone replacement rather than excess.
D. Lethargy and lack of appetite are also symptoms of hypothyroidism, not hyperthyroidism, which would not typically result from an overdose of levothyroxine.
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