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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
By 3 months old, most babies can lift their heads and chest up from a belly-down position.
Choice A is not correct because it is normal for a 3-month-old infant to be unable to roll from back to abdomen.
Choice B is not correct because it is normal for a 3-month-old infant to be unable to use a pincer grasp to pick up objects.
Choice D is not correct because it is normal for a 3-month-old infant to be unable to sit without support.
Correct Answer is D
Explanation
Compartment syndrome is a condition where increased pressure within a muscle compartment causes muscle and nerve damage along with pain.
One of the symptoms of compartment syndrome is severe pain that increases with the stretching of muscles.
Choice A is not correct because blue-looking nail beds on the toes are not a symptom of compartment syndrome.
Choice B is not correct because a weak femoral pulse is not a symptom of compartment syndrome.
Choice C is not correct because the inability to plantarflex the foot is not a symptom of compartment syndrome.
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