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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?

A.

Provide pin care when the client is 4 hours postoperative.

B.

Remove the weights from the traction while repositioning the client in bed.

C.

Assess the client's circulation every 4 hours.

D.

Request the client to perform ankle exercises on the affected extremity.

Answer and Explanation

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.


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Related Questions

Correct Answer is B

Explanation

Choice A rationale:

Hemoptysis, which is the coughing up of blood, is not typically associated with a urinary tract infection (UTI). It is more commonly related to respiratory or pulmonary issues.

Choice B rationale:

Hematuria, the presence of blood in the urine, is a common finding in a UTI. Inflammation and infection in the urinary tract can lead to the presence of blood cells in the urine.

Choice C rationale:

Hyperglycemia, an elevated blood glucose level, is not directly related to a UTI. It may be seen in individuals with diabetes, but it is not a typical finding in a UTI.

Choice D rationale:

Hypocalcemia, a low level of calcium in the blood, is not a characteristic finding in a UTI. UTIs primarily affect the urinary system and do not directly involve calcium metabolism.

Correct Answer is B

Explanation

Let's break down the calculation:

Given:

  • Patient weight: 154 lbs
  • Enoxaparin dosage: 0.75 mg/kg
  • Available enoxaparin: 60 mg/0.6 mL

Step 1: Convert pounds to kilograms:

  • 1 lb is approximately 0.4536 kg
  • So, 154 lbs = 154 * 0.4536 kg/lb = 69.85 kg (approximately 70 kg)

Step 2: Calculate the total dose of enoxaparin:

  • Desired dose = 0.75 mg/kg * 70 kg = 52.5 mg

Step 3: Determine the volume to administer:

  • We have enoxaparin 60 mg/0.6 mL
  • To find the volume for 52.5 mg:
    • (52.5 mg / 60 mg) * 0.6 mL = 0.525 mL
    • Rounded to the nearest tenth, this is 0.5mL.

Therefore, the nurse should administer 0.5mL of enoxaparin

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