A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?
Tie knots in the ropes near the pulleys to shorten them.
Increase the elevation of the affected extremity.
Remove one of the weights.
Pull the client up in bed.
The Correct Answer is D
D. The appropriate action would be to adjust the patient's position to restore the correct alignment and tension of the traction. This typically involves pulling the client up in bed to ensure that the weights hang freely and exert the necessary force for effective traction.
A It is not recommended to tie knots in the ropes as this action could disrupt the prescribed traction force and alignment.
B. It is helpful for other aspects of care but does not correct the traction issue caused by the weights resting on the floor.
C. This is not the correct action because it would decrease rather than increase the traction force, which is necessary for fracture alignment and healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A Nitroglycerin is a vasodilator that helps relieve angina by dilating blood vessels and increasing blood flow to the heart muscle. It is typically the first-line medication for acute angina attacks. Administering nitroglycerin promptly can help alleviate the client's pain and prevent progression to a myocardial infarction (heart attack).
B. Aspirin is often administered to clients with suspected myocardial ischemia or infarction because it inhibits platelet aggregation, which can reduce the risk of clot formation and further occlusion of coronary arteries. It is typically given early in the management of acute coronary syndrome to prevent clotting complications.
C. While monitoring blood pressure is important in clients with acute angina, especially to assess for hypotension which could indicate cardiogenic shock, it is not the first action. Immediate pain relief and prevention of further ischemic damage take precedence over blood pressure measurement.
D. IV access is important for administering medications and fluids if needed, but it is not the first priority unless the client's condition warrants immediate IV medication administration (such as in severe pain or impending myocardial infarction).
Correct Answer is C
Explanation
C. This statement highlights difficulty with a specific ADL (grooming) that OT can assess and intervene to improve independence and quality of life.
A Difficulty swallowing, preference for a wheelchair over a walker, and problems with bladder control may also require medical attention, but they are not directly related to the occupational therapy's primary focus on improving the patient's ability to perform daily activities
B. This statement suggests mobility issues and possibly difficulty with walking due to muscle weakness. While mobility aids such as wheelchairs and walkers are typically addressed by physical therapists, OT can also be involved in evaluating the client's preferences, abilities, and functional mobility needs.
D. While OT primarily focuses on ADLs and functional tasks, bladder control problems typically require evaluation and management by a urologist or specialist in urology.
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