A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?
Check the client for injuries.
Obtain a prescription for medication to sedate the client.
Call the family and ask them to make arrangements for someone to sit with the client.
Assist the client back into bed and apply restraints.
The Correct Answer is A
The first action the nurse should take is to check the client for injuries. The nurse should assess the client for any signs of injury or trauma and provide appropriate care as needed.
Obtaining a prescription for medication to sedate the client, calling the family and asking them to make arrangements for someone to sit with the client, and assisting the client back into bed and applying restraints are not appropriate initial actions for the nurse to take in this situation. These actions may be considered after the client has been assessed for injuries and their immediate needs have been addressed.
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Related Questions
Correct Answer is A
Explanation
a.Skeletal traction is often better than skin traction for reducing and maintaining alignment of a fracture because it involves the insertion of pins, wires, or screws directly into the bone, allowing for greater force and stability.
b.Clients in skin traction typically have less mobility compared to those in skeletal traction. Skin traction is usually used for short-term purposes or less severe fractures and involves attaching weights to the skin using adhesive materials or bandages, which can limit movement to some extent.
c.Skeletal traction involves inserting hardware into the bone, which creates an entry point for potential infection. Therefore, it has a higher risk for infection compared to skin traction, which does not involve invasive procedures.
d.While both types of traction can cause discomfort, skeletal traction is typically more invasive and can be associated with more discomfort and pain due to the pins or wires inserted into the bone. Skin traction, while uncomfortable due to the adhesive and pressure on the skin, generally causes less discomfort than skeletal traction.
Correct Answer is A
Explanation
If a client returns to the surgical unit from the PACU in skeletal traction and the weights rest against the foot of the bed, the nurse should take action to correct this problem with the traction setup. The weights should be hanging freely and not touching any part of the bed or floor. This ensures that the traction is providing the appropriate amount of force to the affected limb.
The other options listed are not problems with the traction setup. The ropes should be in the center of the wheel grooves, the weights should be equal on each side, and the ropes should attach securely to the pin.
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