A nurse is caring for a client who has a fractured hip and was placed in skeletal traction 2 hours ago. Which of the following actions should the nurse take?
Provide pin care when the client is 4 hours postoperative.
Remove the weights from the traction while repositioning the client in bed.
Assess the client's circulation every 4 hours.
Request the client to perform ankle exercises on the affected extremity.
The Correct Answer is C
Choice A rationale:
Providing pin care when the client is 4 hours postoperative is not appropriate. The client has just undergone skeletal traction placement, and pin care is usually initiated after 24 hours to allow for initial wound healing.
Choice B rationale:
Removing the weights from the traction while repositioning the client in bed is unsafe and not recommended. The weights should remain in place to provide continuous traction and alignment for the fractured hip.
Choice C rationale:
Assessing the client's circulation every 4 hours is essential to monitor for any signs of impaired circulation, such as swelling, pallor, or decreased pulses. Early detection of circulatory compromise is critical to prevent complications like compartment syndrome.
Choice D rationale:
Requesting the client to perform ankle exercises on the affected extremity is not appropriate after skeletal traction placement. Ankle exercises could disrupt traction and hinder the healing process of the fractured hip.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Wearing gloves when changing the cat's litter box is essential during chemotherapy because some chemotherapy drugs can be excreted in bodily fluids, including feces. Protecting against direct contact with potentially harmful substances is crucial to minimize exposure risks.
Choice B rationale:
Taking the temperature once each week is not a relevant precaution during chemotherapy. Monitoring temperature is important, but it should be done more frequently, such as daily, as chemotherapy can cause immunosuppression, increasing the risk of infection.
Choice C rationale:
Being able to attend a concert is not related to precautions during chemotherapy. It is essential for clients undergoing chemotherapy to avoid large gatherings and events where they might be exposed to infections.
Choice D rationale:
Allowing the toothbrush to dry completely between each use is a good hygiene practice but not specifically related to chemotherapy precautions. Proper oral hygiene is essential during chemotherapy, but using a soft toothbrush and regularly replacing it are more relevant considerations.
Correct Answer is D
Explanation
Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.
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