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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Swelling around the eyelids and mouth could indicate an allergic reaction, which can be severe in some cases. Anaphylaxis is a life-threatening reaction that can occur after immunizations. The nurse's priority is to assess and address any signs of an allergic reaction promptly. Swelling of the face, particularly around the eyes and mouth, is a red flag for potential anaphylaxis, and immediate intervention is necessary to prevent further complications.
Choice B rationale:
A temperature of 100.7 degrees Fahrenheit is considered a mild fever. While it's important to monitor for fever after immunizations, a mild fever alone may not be the nurse's top priority, especially if the child is otherwise stable. Fever can be a common post-immunization response and is often self-limiting.
Choice C rationale:
While monitoring the child's intake is important, only eating 2 ounces during the last feeding is not a priority concern compared to potential allergic reactions or fever. A temporary decrease in appetite following immunizations can be expected and might resolve on its own.
Choice D rationale:
Crying when the injection site is touched is a common response to discomfort from the shot. While it's essential to provide comfort and support to the child, this finding is not indicative of a severe reaction. It's not the nurse's priority compared to potential signs of an allergic reaction or a more significant fever.
Correct Answer is C
Explanation
Choice A rationale:
Washing the child's pillow in cold water twice monthly is not a relevant instruction for controlling allergens in asthma management. Asthma triggers are often related to airborne allergens such as dust mites, pollen, and pet dander, and focusing on pillow washing alone does not address the broader issue of allergen exposure.
Choice B rationale:
Using a humidifier in the child's bedroom can actually worsen asthma symptoms. Humidifiers can increase the humidity in the air, promoting the growth of mold and dust mites, which are common allergens that can trigger asthma symptoms. Therefore, this instruction is not appropriate for asthma management.
Choice C rationale:
This is the correct answer. Using a damp cloth to dust the child's furniture weekly is a relevant instruction for controlling allergens. Dusting with a damp cloth helps to capture and remove allergens such as dust mites, pollen, and pet dander from surfaces, reducing the child's exposure to these triggers and potentially minimizing asthma symptoms.
Choice D rationale:
Installing carpet in the child's bedroom is not recommended for asthma management. Carpets can harbor dust mites, mold, and other allergens that can exacerbate asthma symptoms. Hard flooring surfaces that can be easily cleaned and do not trap allergens are a better choice for individuals with asthma.
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