A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown?

Apply lotion to the skin around the edges of the splint.

Turn the client every 4 hr.

Pad the top of the splint with protective dressings.

The nurse should apply a footplate to the bed.

Answer and Explanation

The Correct Answer is C

Choice A reason: Applying lotion to the skin around the edges of the splint may increase moisture and friction, which can contribute to skin breakdown. It is better to use protective dressings to reduce friction.

Choice B reason: Turning the client every 4 hours is not frequent enough. Clients in skeletal traction should be repositioned frequently, typically every 2 hours, to prevent pressure ulcers and maintain skin integrity.

Choice C reason: The correct answer is c because padding the top of the splint with protective dressings helps reduce friction and pressure on the skin, preventing skin breakdown and ensuring the client's comfort.

Choice D reason: Applying a footplate to the bed is not directly related to preventing skin breakdown. The primary focus should be on reducing friction and pressure around the splint.

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Correct Answer is D

Explanation

Choice A reason: While a thallium scan can provide information about the heart's functional capacity, it is more specifically used to detect areas of the heart muscle that are not receiving adequate blood supply.

Choice B reason: A thallium scan does not identify heart rhythm disturbances. This is typically evaluated with an electrocardiogram (ECG) or Holter monitor.

Choice C reason: The size of the chambers of the heart is usually assessed through echocardiography or other imaging techniques, not a thallium scan.

Choice D reason: The correct answer is d because a thallium scan detects damage to the heart muscle by identifying areas with reduced blood flow, which may indicate ischemia or previous infarction.

A. Excessive thrombosis and bleeding. B. Progressive increase in platelet production. C. Immediate sodium and fluid retention. D. Increased clotting factors.

Correct Answer is A

Explanation

Choice A reason: Disseminated intravascular coagulation (DIC) is a condition characterized by both excessive clotting and excessive bleeding. The clotting cascade is inappropriately activated throughout the body, leading to the formation of numerous small blood clots in the blood vessels. These clots consume clotting factors and platelets, which can then lead to excessive bleeding. This paradoxical combination of thrombosis and bleeding is a hallmark of DIC.

Choice B reason: In DIC, platelet consumption exceeds production. The formation of numerous clots uses up platelets faster than they can be produced, which can result in thrombocytopenia and bleeding. Therefore, a progressive increase in platelet production is not an expected finding in DIC.

Choice C reason: Immediate sodium and fluid retention is not a feature of DIC. This condition primarily involves the clotting and bleeding mechanisms, not fluid balance or sodium levels.

Choice D reason: In DIC, clotting factors are consumed in the formation of numerous clots. This leads to a deficiency of clotting factors, contributing to the bleeding tendency seen in this condition. Increased clotting factors would not be expected in a patient with DIC.

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A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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