A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction.
Which of the following actions should the nurse take?
Ensure the client's weights are hanging freely from the bed.
Check the client's bony prominences every 12 hr.
Cleanse the client's pin sites with povidone-iodine.
Loosen the knots on the ropes if the client is experiencing pain.
The Correct Answer is A
Choice A rationale
Ensuring the client's weights are hanging freely from the bed is crucial in maintaining the proper amount of traction force. This prevents complications and ensures that the traction is effective in reducing the fracture and alleviating pain.
Choice B rationale
Checking the client's bony prominences every 12 hours is important for preventing pressure ulcers and skin breakdown. However, the timing might need to be more frequent depending on the client's overall health and risk factors.
Choice C rationale
Cleansing the client's pin sites with povidone-iodine is a common practice to prevent infection. However, current guidelines often recommend alternative cleaning solutions, such as chlorhexidine, due to better evidence of efficacy.
Choice D rationale
Loosening the knots on the ropes if the client is experiencing pain can compromise the effectiveness of the traction. Adjustments should be made by a healthcare professional to ensure the correct amount of force is applied without causing additional harm.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Distracting the child by buying a toy can reinforce the tantrum behavior by teaching the child that tantrums result in rewards. This can lead to an increase in tantrum frequency as the child learns to manipulate situations to get new toys or other desired items.
Choice B rationale
Appearing to ignore the child during a tantrum helps to extinguish the behavior over time. By not giving attention to the tantrum, the child learns that this behavior does not achieve their desired outcome. Consistency is key in this approach to ensure the child understands that tantrums are ineffective.
Choice C rationale
Placing the child in time-out for 3 minutes can be effective in some cases, but it may not be the first recommendation. Time-out removes the child from a stimulating environment and gives them time to calm down. However, it may not address the underlying reasons for the tantrum.
Choice D rationale
Calmly telling the child to stop might not be effective during the peak of a tantrum. Toddlers in the midst of a tantrum often cannot process verbal instructions or reasoning, so this approach may not achieve the desired result.
Correct Answer is C
Explanation
Choice A rationale
Walks with one hand held typically occurs around 12 months as infants gain balance and coordination for upright movement.
Choice B rationale
Sits unsupported usually happens around 6 months when infants' core muscles are strong enough to hold their torso upright.
Choice C rationale
Turning pages in a book is a fine motor skill that develops around 12 months as hand-eye coordination improves.
Choice D rationale
Rolling from front to back typically occurs around 6 months as infants develop stronger neck and upper body muscles.
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