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 D
Explanation
Choice A rationale:
Popcorn can be problematic for a child with Crohn's disease. Crohn's disease is characterized by inflammation in the gastrointestinal tract, and certain high-fiber foods like popcorn can exacerbate symptoms, causing discomfort and potential irritation of the intestinal lining.
Choice B rationale:
Hot dogs are typically high in fat and can be difficult to digest, which can trigger symptoms in a child with Crohn's disease. Additionally, processed meats like hot dogs might contain additives that could worsen inflammation in the digestive tract.
Choice C rationale:
Dried apricots are also not the best choice for a child with Crohn's disease. Dried fruits are concentrated sources of fiber and can be tough on the digestive system, potentially leading to abdominal pain and diarrhea in individuals with inflamed intestines.
Choice D rationale:
Plain yogurt is a suitable food choice for a child with Crohn's disease. It is a good source of protein and calcium and contains probiotics that can promote gut health. Probiotics may help regulate the digestive system and alleviate some symptoms associated with Crohn's disease. However, individual tolerances may vary, so it's important to monitor the child's response to yogurt.
Correct Answer is B
Explanation
Choice A rationale:
Positioning the child sitting with their buttocks at the edge of the table is not appropriate for collecting a bone marrow specimen from a preschooler. This position does not provide adequate access to the bone marrow aspiration site and may lead to discomfort for the child.
Choice B rationale:
Placing the child in a prone position (lying face down) is suitable for collecting a bone marrow specimen from a preschooler. This position exposes the posterior iliac crest, which is a common site for bone marrow aspiration. It allows for easier access to the bone marrow and reduces the risk of injury.
Choice C rationale:
Positioning the child side-lying to expose the vertebrae is not the recommended position for bone marrow aspiration. The iliac crest, not the vertebrae, is the usual site for this procedure in children. Placing the child in a side-lying position would make it difficult to access the appropriate site.
Choice D rationale:
Placing the child supine with legs flexed outward into a frog-like position is suitable for collecting a bone marrow specimen. This position provides access to the iliac crest while allowing for better immobilization of the child. It also ensures the child's safety and comfort during the procedure.
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