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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: The statement that a DNR prescription means the client will only receive pain medication is incorrect. A DNR (Do Not Resuscitate) order does not affect the provision of treatments other than those required to resuscitate the patient if their heart stops or they stop breathing. Patients with a DNR can still receive all other medical treatments and interventions aimed at managing symptoms and improving quality of life, including pain management.

Choice B reason: A DNR prescription does not limit the current treatment regimen in terms of ongoing treatments for the patient's condition. The DNR order specifically refers to not performing CPR (cardiopulmonary resuscitation) if the patient's breathing or heart stops. All other aspects of the patient's care plan, including aggressive treatments, can continue if they align with the patient's wishes and medical advice.

Choice C reason: This is the correct statement. A DNR prescription allows the patient to continue with their current treatment regimen. It is a directive that applies only in the event of cardiac or respiratory arrest, indicating that CPR should not be performed. However, it does not preclude the patient from receiving other medical treatments or interventions.

Choice D reason: A DNR prescription does not inherently limit the ability to receive invasive procedures. The decision to pursue or avoid invasive procedures would be based on the patient's overall treatment goals, prognosis, and personal preferences, not solely on the presence of a DNR order.

A. Digoxin B. Sotalol C. Atropine D. Lidocaine

Correct Answer is C

Explanation

Choice A reason: Digoxin is primarily used to treat atrial fibrillation and heart failure. It is not the first-line medication for sinus bradycardia with ST-segment elevation, as it can further slow down the heart rate.

Choice B reason: Sotalol is a beta-blocker and an antiarrhythmic medication that can be used to treat ventricular arrhythmias and maintain sinus rhythm in atrial fibrillation. However, it is not indicated for sinus bradycardia and could exacerbate the condition.

Choice C reason: Atropine is the medication of choice for symptomatic sinus bradycardia. It works by blocking the action of the vagus nerve on the heart, leading to an increased heart rate. Atropine can quickly reverse the symptoms of bradycardia, such as dizziness and shortness of breath.

Choice D reason: Lidocaine is an antiarrhythmic medication used to treat ventricular arrhythmias. While it can be used in acute settings, it is not the first choice for sinus bradycardia with ST-segment elevation.

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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?

Nursing Test Bank

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