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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The statement "You should limit discussing past events with the client" does not necessarily incorporate the client's and family's cultural beliefs. Discussing past events can be a part of reminiscence therapy, which can be beneficial for clients with terminal illnesses. It allows them to reflect on their life experiences and can provide a sense of fulfillment or closure.
Choice B reason: Saying "We will respect what is important to you" is a broad and inclusive statement that acknowledges the importance of the client's and family's cultural beliefs. It implies that the care team is willing to listen and adapt the care plan to align with the client's values, which is a fundamental aspect of culturally competent care. This approach can help ensure that the client's end-of-life care is respectful and responsive to their individual needs.
Choice C reason: Offering to "arrange all burial services" may not be appropriate as it assumes that the family requires assistance with this aspect of care without first understanding their specific cultural or religious practices. It is important to have a conversation with the client and family about their preferences and needs regarding end-of-life rituals before making any arrangements.
Choice D reason: The statement "Grieving should not be done in front of the client" may not align with the cultural beliefs of the client and family. Grieving practices vary widely among different cultures, and some may find it important to express grief openly in the presence of the dying person. It is essential to respect and accommodate the family's grieving process.
Correct Answer is C
Explanation
Choice A reason: Anticonvulsants are medications used to prevent seizures. While seizures can occur after a stroke, anticonvulsants are not routinely prescribed unless the patient has a history of seizures or has experienced seizures post-stroke. Therefore, anticonvulsants would not be the standard pharmacologic therapy for all patients being discharged after an ischemic stroke.
Choice B reason: Diuretics are used to remove excess fluid from the body and are commonly prescribed for conditions such as heart failure or high blood pressure. They are not typically used as a standard treatment for ischemic stroke unless the patient has a specific condition that requires fluid management.
Choice C reason: Antithrombotic agents, such as aspirin or clopidogrel, are commonly prescribed to patients after an ischemic stroke to prevent further clot formation and reduce the risk of recurrent strokes. These medications work by inhibiting platelet aggregation and are a key part of secondary prevention in stroke management.
Choice D reason: Opioid analgesics are strong painkillers that are used to treat severe pain. They are not typically prescribed upon discharge for ischemic stroke patients unless there is a specific indication for pain management that cannot be managed with other medications.
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