A nurse is assisting with the care of an adolescent client who is in skeletal traction for the treatment of a fractured femur. Which of the following actions should the nurse take?
Gently lift the traction weights off the floor when repositioning the client.
Reduce intake of foods containing fiber while nonambulatory.
Perform passive range-of-motion exercises to the affected extremity every 2 hours.
Apply protective padding to the end of the pin sites.
The Correct Answer is D
Choice A rationale:
Gently lift the traction weights off the floor when repositioning the client. Rationale: This choice is not recommended in the care of a client in skeletal traction. Traction weights should never be lifted off the floor as they provide the necessary counter traction to align and immobilize the fractured bone. Lifting the weights could disrupt the traction and jeopardize the healing process.
Choice B rationale:
Reduce intake of foods containing fiber while nonambulatory. Rationale: While constipation can be a concern for clients in skeletal traction due to decreased mobility, reducing fiber intake is not the appropriate intervention. Adequate fiber intake is important to promote regular bowel movements and prevent constipation. Hydration and mobility exercises are more suitable approaches to manage constipation.
Choice C rationale:
Perform passive range-of-motion exercises to the affected extremity every 2 hours. Rationale: Passive range-of-motion exercises are important to maintain joint mobility and prevent muscle atrophy in a nonambulatory client. However, performing these exercises every 2 hours might be excessive and could cause unnecessary discomfort for the client. Range-of-motion exercises are usually done every 4 to 8 hours to strike a balance between maintaining joint health and providing rest.
Choice D rationale:
Apply protective padding to the end of the pin sites. Rationale: This is the correct choice. Applying protective padding to the end of the pin sites is crucial to prevent pressure ulcers and infection. The pin sites are potential entry points for bacteria, and protecting them helps reduce the risk of infection. Padding also prevents pressure on the skin and underlying tissues, reducing the potential for pressure injuries.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Acute otitis media is not a risk factor for physical maltreatment. It's an ear infection and does not directly contribute to the risk of physical abuse. The child's medical history should be assessed for factors that are more closely related to abuse.
Choice B rationale:
Myopia, or nearsightedness, is also not a risk factor for physical maltreatment. Myopia is a visual impairment and is not related to the risk of abuse. The nurse should focus on identifying factors that might indicate an increased likelihood of abuse.
Choice C rationale:
Prematurity can be a risk factor for various health issues in a child, but it is not directly linked to physical maltreatment. While preterm infants might have unique medical needs, being born prematurely does not inherently increase the risk of physical abuse.
Choice D rationale:
Correct Answer. Being adopted can be considered a potential risk factor for physical maltreatment. Children who are adopted might face certain challenges related to attachment, identity, and adjustment. It's important for healthcare providers to be vigilant and assess the child's situation comprehensively to ensure their safety and well-being.
Correct Answer is B
Explanation
Choice A rationale:
The Rotavirus vaccine is typically administered to infants, usually starting at 2 months of age, to protect against severe diarrhea and vomiting caused by rotavirus infection. However, the child in question is 11 years old, and the rotavirus vaccine is not recommended for administration at this age. The vaccine's protection window is within the infant and early childhood period, and the child would likely have received this vaccine earlier.
Choice B rationale:
Haemophilus influenzae type b (Hib) Hib vaccine is recommended as a series of doses to protect against Haemophilus influenzae type B infection, which can lead to severe illnesses like meningitis and pneumonia. While the child may have received this vaccine in infancy, a booster dose is often recommended around age 11 to ensure ongoing protection. This choice is correct for the given age group.
Choice C rationale:
Hepatitis A Hepatitis A vaccine is typically administered in two doses, with the first dose given at age 1 and the second dose administered at least 6 months later. The child in question is 11 years old, and assuming the child received the vaccine as per the standard schedule, there would be no need to administer this vaccine again.
Choice D rationale:
Human papillomavirus (HPV) HPV vaccine is recommended for adolescents to protect against several strains of the human papillomavirus that can lead to various cancers later in life. It's usually administered in a series of doses starting around age 11 or 12. However, the prompt states that the child is already up-to-date with current immunizations, and if the child received the HPV vaccine at the appropriate age, there would be no need for another dose at this time.
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