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.

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The client is at highest risk for wound infection as evidenced by the blood glucose level

Rationale

Type 2 diabetes mellitus: The client has poorly controlled diabetes with a preoperative Hemoglobin A1C of 9.5% and elevated glucose levels (280 mg/dL currently). Elevated blood glucose levels impair immune function and increase the risk of surgical site infections, including wound infections.

Postoperative state: After total knee arthroplasty, surgical wounds are vulnerable to infection. Hyperglycemia (high blood glucose levels) further increases susceptibility to infections due to impaired wound healing and compromised immune response.

Evidence: The client's current blood glucose level of 280 mg/dL (normal range 74 to 106 mg/dL) indicates poor glycemic control, which is a significant risk factor for developing wound infections postoperatively.

A. The client advances their right foot to meet their left foot. B. The client maintains two points of support on the floor. C. The client holds the cane in their left hand. D. The client moves the cane forward 50.8 cm (20 in) when ambulating.

Correct Answer is B

Explanation

B. When using a quad cane, the client should always maintain two points of support on the floor: the cane and either the affected (left) or unaffected (right) leg. This ensures stability and support while walking.

A When using a quad cane, the client should advance their weaker (left) foot and then the stronger (right) foot. This allows the cane to provide support on the weaker side.

C. This action is correct for a client with left-sided hemiparesis. The quad cane should be held on the stronger side (right hand) to provide support for the weaker side (left leg).

D. This statement is unclear in terms of the context provided. However, typically when using a quad cane, the cane is moved forward a comfortable distance with each step to provide continuous support and balance. The exact distance may vary depending on the client's stride length and comfort.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a total knee arthroplasty Exhibits The client is at highest risk for dropdown as evidenced by the dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A nurse is instructing a client who has left-sided hemiparesis about the use of a quad cane. Which of the following actions by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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