A nurse in a health clinic is caring for a client.

Exhibits

Select 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing 

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due to 

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B. Providing the client with a trapeze bar allows them to move and reposition in bed independently without compromising the traction on the affected leg.

A Checking pressure points every 2 hours is generally recommended for clients at risk of developing pressure ulcers, but it's not specific to skeletal traction care.

C. Removing the weights prematurely can lead to loss of traction and compromise the therapeutic benefit of the traction.

D. When a client has skeletal traction, they should avoid using the affected limb for any weight-bearing activities or for repositioning

The nurse should first address the client pain level followed by the client's ECG results

Rationale

Pain level: Addressing the client's pain level is crucial because it directly affects their comfort and can be indicative of ongoing myocardial ischemia or infarction. The client initially reported chest pain as 7/10, which is significant. Although it has decreased to 5/10 after nitroglycerin, ongoing assessment of pain is essential to ensure it does not worsen or change in nature.

ECG results: The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes. These findings indicate acute myocardial ischemia or infarction, which is a critical concern. The ECG results guide further diagnosis and treatment decisions, such as determining the need for immediate reperfusion therapy (like thrombolytics or angioplasty).