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.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A 23-year-old client in skeletal traction may be at risk of pressure injuries, but being young and presumably healthier than the other options, this client may have a lower risk compared to the other choices.
Choice B rationale:
A 67-year-old client with coronary artery disease may be at risk of pressure injuries, especially if the client has limited mobility or is bedridden. However, coronary artery disease alone does not significantly increase the risk of pressure injuries.
Choice C rationale:
A 32-year-old client with a spinal cord injury is most at risk of developing a pressure injury. Spinal cord injuries often result in paralysis or limited mobility, leading to prolonged pressure on specific areas of the body, which can cause pressure ulcers.
Choice D rationale:
A 55-year-old client with emphysema may have compromised lung function, but this alone does not significantly increase the risk of pressure injuries. Pressure injuries are primarily related to immobility and pressure on specific body areas.
Correct Answer is C
Explanation
Choice A rationale:
A blood glucose level of 100 mg/dL is within the normal range, so there is no need to notify the provider of this finding.
Choice B rationale:
A client's temperature of 37.6°C (99.7°F) is slightly elevated but not considered a critical finding. It may be indicative of an infection or other mild inflammation, but it does not warrant immediate provider notification.
Choice C rationale:
A potassium level of 5.7 mEq/L is above the normal range (3.5-5.0 mEq/L). Hyperkalemia can lead to serious cardiac complications, such as arrhythmias, and requires immediate attention from the provider.
Choice D rationale:
Weight loss of 0.8 kg/day (1.8 lb/day) should be evaluated and monitored, but it is not an immediate concern that warrants urgent provider notification.
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