A nurse is caring for a client who has skeletal traction for the treatment of a femur fracture.
Which of the following actions should the nurse take?
Position the weights on the traction so they are touching the head of the client's bed
Encourage isometric exercises every 8 hr
Administer pain medication to the client before performing pin care
Assist the client to shift position every 4 hr.
The Correct Answer is C
Choice A reason:
Placing traction weights so they touch the head of the bed disrupts the effectiveness of the traction system. Skeletal traction relies on a continuous pulling force to maintain proper alignment of the fractured femur. If the weights are resting on any surface, the force is interrupted, which can lead to complications such as malunion or delayed healing. The weights must hang freely at all times to ensure therapeutic benefit.
Choice B reason:
Isometric exercises are beneficial for maintaining muscle tone and promoting circulation during immobilization. However, while this is a supportive intervention, it is not the most critical or immediate nursing action in the context of skeletal traction. Encouraging exercises every 8 hours is appropriate, but it does not directly address the most urgent or discomfort-related aspect of care.
Choice C reason:
Pin care is a routine but potentially painful procedure associated with skeletal traction. Administering pain medication beforehand is a priority nursing action because it ensures client comfort, reduces anxiety, and promotes cooperation during the procedure. This intervention reflects both compassionate care and adherence to best practices in pain management and infection prevention.
Choice D reason:
Repositioning a client in skeletal traction must be done with extreme caution to avoid disrupting the traction setup. Assisting the client to shift position every 4 hours may inadvertently alter the alignment or tension of the traction apparatus. While pressure injury prevention is important, repositioning must be coordinated carefully and is not the most appropriate standalone action in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The Ortolani test is a screening test that would help rule out a hip problem related to babies who are breech.
It is used to check for developmental dysplasia of the hip (DDH).
Choice A is not an answer because bracing is a treatment for DDH, not a screening test.
Choice B is not an answer because genu valgum is a condition where the knees angle in and touch each other when the legs are straightened, and it is not a screening test for DDH.
Choice C is not an answer because the Adams test is used to screen for scoliosis, not DDH.
Correct Answer is A
Explanation
Allowing the child to choose an article or two of clothing that she can wear with the brace can help her feel more confident and in control of her appearance.
This can help her feel better about wearing the brace and improve her overall attitude toward the treatment.
Choice B is not the best answer because it focuses on the long-term benefits of the treatment without addressing the child’s immediate concerns and emotions.
Choice C is not the best answer because it suggests that the child should be left alone to deal with her emotions, which may not be helpful in this situation.
Choice D is not the best answer because it suggests comparing the child’s situation to others who are sicker, which may not be helpful or appropriate.
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