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 D
The nurse should assist the client to shift position every 4 hours to prevent complications such as pressure ulcers and pneumonia.
Choice A is incorrect because the weights on the traction should be freely hanging and not touching any part of the bed.
Choice B is incorrect because isometric exercises may not be appropriate for a client with a femur fracture and should be prescribed by a healthcare provider.
Choice C is incorrect because administering pain medication before performing pin care may not be necessary and should be based on the client’s level of pain and the healthcare provider’s orders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A soft toy that squeaks or crackles when squeezed is a good choice for a 7- month-old infant.
At this age, babies love to explore using their mouths and hands, and they might start teething around 6 months old.
A soft toy that makes noise when squeezed can provide sensory stimulation and help with the development of fine motor skills.
A set of blocks to build a block tower is not suitable for a 7-month-old infant as they are still developing their motor skills.
A colorful crib mobile that plays music is more suitable for younger infants.
A wooden farm animal puzzle with large pieces is not suitable for a 7-month-old infant as they are still developing their cognitive and motor skills.
Correct Answer is A
Explanation
The correct answer is a. Positive Moro reflex.
Choice A reason:
Positive Moro reflex: This reflex should disappear by 6 months of age. Its presence at 9 months indicates potential neurological issues.
Choice B reason:
Negative Doll’s eye reflex: This reflex, indicating brainstem function, should be positive in infants. A negative result suggests severe brainstem dysfunction
Choice C reason:
Positive Babinski reflex: This reflex is normal up to 2 years of age. It indicates normal neurological development in infants.
Choice D reason:
Negative Crawl reflex: Crawling typically develops between 6-10 months. A negative crawl reflex at 9 months could indicate developmental delays
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