A nurse is caring for a client who is in skeletal traction. Which of the following actions should the nurse take?
Unscrew the pins to cleanse the pin sites.
Remove the weights while turning the client in bed.
Loosen the rope knots holding the weights for 30 min if the client reports pain.
Ensure that there is at least 4.5 kg (10 lb) of weight applied to the client's traction.
The Correct Answer is D
A. Unscrew the pins to cleanse the pin sites: Unscrewing the pins is incorrect as it can compromise the stability of the traction and increase the risk of infection. Pin site care should be performed according to the facility's protocol without disturbing the pins.
B. Remove the weights while turning the client in bed: Removing weights is incorrect as it can disrupt the alignment and effectiveness of the traction. Weights should be left in place to maintain proper traction and alignment.
C. Loosen the rope knots holding the weights for 30 min if the client reports pain: Loosening the rope knots is inappropriate and can interfere with the traction's effectiveness. Pain management should involve assessing the client's comfort and reviewing the traction setup, but not altering the traction itself.
D. Ensure that there is at least 4.5 kg (10 lb) of weight applied to the client's traction: This is correct as maintaining the appropriate amount of weight is crucial for proper skeletal traction. Ensuring that the prescribed weight is applied helps in achieving the desired therapeutic effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Place the client in a negative-pressure airflow room: This is correct as these symptoms are indicative of tuberculosis (TB), which requires airborne precautions. A negative-pressure room helps to prevent the spread of airborne pathogens.
B. Wear a surgical mask when entering the client's room: This is incorrect because a surgical mask does not provide adequate protection against airborne particles; an N95 respirator is necessary for airborne precautions.
C. Have a container for soiled linens outside the client's door: This is incorrect as soiled linens should be handled and disposed of within the room under appropriate infection control protocols, not just placed outside.
D. Remain within 91.4 cm (3 ft) of the client: This is incorrect as maintaining this distance does not prevent the spread of airborne diseases. Proper airborne precautions, including the use of personal protective equipment, are necessary.
Correct Answer is A
Explanation
A. Use the client's left arm to obtain blood samples: This is correct as using the arm on the opposite side of the mastectomy helps avoid additional stress or injury to the affected arm, which can help prevent lymphedema.
B. Keep both arms below the level of the client's heart: This is not recommended as elevating the affected arm can help reduce swelling and promote lymphatic drainage.
C. Limit range-of-motion exercises with the affected arm: This is incorrect as range-of-motion exercises are important to prevent stiffness and promote circulation, which helps reduce the risk of lymphedema.
D. Obtain blood pressure readings using the client's right arm: This is incorrect as obtaining blood pressure on the affected side could increase the risk of lymphedema.
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