A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?
Remove the weights before changing the client's bed linens.
Instruct the client to use their elbows to reposition.
Check pressure points every 12 hours.
Provide the client with a trapeze bar.
The Correct Answer is D
Choice A reason: Removing the weights before changing the client's bed linens is not recommended. The weights are an integral part of the traction system and removing them could disrupt the traction, potentially causing harm or discomfort to the client. The weights must be maintained to ensure the effectiveness of the skeletal traction.
Choice B reason: Instructing the client to use their elbows to reposition themselves could be helpful, but it is not the primary action the nurse should take. While maintaining some degree of mobility is important, the nurse must ensure that the traction setup is not disturbed during any movement.
Choice C reason: Checking pressure points every 12 hours is important to prevent skin breakdown and ulcers, especially in immobilized patients. However, this is a routine action and not specific to the care of a client with skeletal traction. The nurse should check pressure points more frequently, considering the increased risk of pressure sores in immobilized patients.
Choice D reason: Providing the client with a trapeze bar is the correct action. A trapeze bar allows the client to independently reposition themselves while maintaining the integrity of the traction. It helps the client to move and shift weight, which can aid in preventing complications such as pressure ulcers and muscle atrophy. It also gives the client a sense of control and independence in their care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The statement that "the spacer should make a whistling sound as you inhale" is not accurate. A whistling sound from the spacer may indicate that the air is being inhaled too quickly and that the user needs to slow down. The purpose of the spacer is to hold the medication released from the inhaler so that it can be inhaled more easily and effectively into the lungs, not to produce a whistling sound.
Choice B reason: Holding one's breath for 10 seconds after inhaling the medication allows for better deposition of the medication in the lungs. This pause gives the medication time to settle in the airways rather than being exhaled too quickly. It is a recommended practice to maximize the effectiveness of the inhaled medication.
Choice C reason: Cleaning the spacer is important to ensure that it works correctly and is free of any residue or debris that could obstruct the medication's path. However, the instruction to "clean the spacer daily with cold water" is incomplete. After rinsing with cold water, the spacer should be left to air dry without rinsing or wiping, as this can create static that affects medication delivery.
Choice D reason: Waiting 30 seconds between puffs is recommended to allow the user to breathe normally for a short period and to prepare for the next dose of medication. This time interval helps to ensure that the second puff is not rushed and that the medication from the first puff has had time to act.
Correct Answer is D
Explanation
Choice A reason: A client with diabetes mellitus presenting with acute ketoacidosis does not necessarily require a private room unless there are other infection control concerns. Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when the body produces high levels of blood acids called ketones. It is a medical emergency that requires treatment in a hospital, but it is not contagious.
Choice B reason: An older adult client admitted with aspiration pneumonia would not typically require a private room solely based on this condition. Aspiration pneumonia is caused by inhaling food, stomach acid, or saliva into the lungs. It can lead to a bacterial infection, which may or may not be contagious depending on the causative organism.
Choice C reason: A client with a compound fracture of the right femur would not require a private room based on the diagnosis alone. A compound fracture, also known as an open fracture, is a fracture in which there is an open wound or break in the skin near the site of the broken bone. While it requires immediate medical attention to prevent infection, it is not a condition that necessitates isolation.
Choice D reason: A client who reports having fever, night sweats, and cough for 2 days may require a private room due to the possibility of an infectious disease that could be transmitted to others, such as tuberculosis (TB). These symptoms are concerning for TB, which is an airborne infectious disease and would require airborne precautions, including a private room with negative pressure ventilation.
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