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 B
Explanation
A. "I should take my supplement with an antacid to prevent an upset stomach": This is incorrect as antacids can interfere with the absorption of iron. Iron supplements should be taken on an empty stomach for better absorption.
B. "I should increase my fiber intake while taking this supplement": This is correct as increasing fiber can help manage constipation, a common side effect of iron supplementation.
C. "I should drink my liquid iron supplement undiluted": This is incorrect. Liquid iron supplements should be diluted to prevent staining of teeth and to improve tolerance.
D. "I should notify my doctor if my stools turn black": This is incorrect because black stools are a common side effect of iron supplementation and are generally not a cause for concern.
Correct Answer is A
Explanation
A. Leaning forward: This is correct as the client should be in a sitting position with arms resting on a table or a support to allow the lungs to expand and make the pleural space more accessible for the procedure.
B. Prone: This is incorrect because the prone position would not provide the necessary access to the pleural space and would be uncomfortable for the procedure.
C. Lithotomy: This is incorrect as the lithotomy position is used for gynecological procedures, not for thoracentesis.
D. Knees elevated: This is incorrect because elevating the knees is not a suitable position for thoracentesis and does not facilitate access to the pleural space.
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