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 B

Explanation

Choice A reason: This statement does not indicate a need for further instruction. It is recommended to wait at least 30 minutes after taking alendronate before taking other medications to ensure proper absorption of the drug.

Choice B reason: This statement indicates a need for further instruction. Alendronate should be taken with plain water, not milk. Milk and other dairy products can interfere with the absorption of alendronate due to their calcium content.

Choice C reason: This statement does not indicate a need for further instruction. Patients are advised to remain upright for at least 30 minutes after taking alendronate to prevent esophageal irritation or ulceration.

Choice D reason: This statement does not indicate a need for further instruction. Periodic bone density tests are a standard part of monitoring the effectiveness of osteoporosis treatment.

A. A client who has a headache following a grade 1 concussion. B. A client who has experienced brain death and is awaiting organ procurement. C. A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash. D. A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack.

Correct Answer is C

Explanation

Choice A reason: A headache following a grade 1 concussion, while requiring monitoring, does not typically necessitate immediate proximity to the nurses' station. Grade 1 concussions are considered mild and usually do not involve loss of consciousness.

Choice B reason: A client who has experienced brain death and is awaiting organ procurement will not benefit from being close to the nurses' station due to the irreversible nature of brain death. The care for such a client is focused on maintaining organ viability for transplantation.

Choice C reason: A client with a score of 10 on the Glasgow Coma Scale following a motor vehicle crash should be placed closest to the nurses' station. A GCS score of 10 indicates a moderate level of impairment in consciousness and potentially unstable vital signs, requiring close monitoring and rapid nursing intervention.

Choice D reason: A score of 0 on the NIH Stroke Scale indicates no observable neurological deficit. Clients with a transient ischemic attack (TIA) and a score of 0 would require less intensive observation compared to those with higher scores or other acute neurological injuries.

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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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Explanation

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