A nurse is caring for a client who is in skin traction. Which of the following actions should the nurse take?

Ensure the weights hang freely from the bed.

Inspect the client's skin every 12 hours for signs of breakdown.

Loosen the ropes of the pulleys when repositioning the client in bed.

Maintain 6.8 kg (15 lb) of weight for the skin traction.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Ensuring that the weights hang freely from the bed is crucial in skin traction. The weights provide a constant and steady force necessary to achieve the therapeutic goal of traction, which is to align and stabilize a fractured bone. If the weights touch the floor or are obstructed, the traction will not be effective, potentially compromising the healing process.

Choice B Reason:
Inspecting the client's skin every 12 hours for signs of breakdown is important but not the highest priority. Skin breakdown can occur due to prolonged pressure from the traction equipment. Regular inspection helps in early identification and management of any skin issues, thus preventing complications such as infections or ulcers.

Choice C Reason:
Loosening the ropes of the pulleys when repositioning the client in bed is incorrect. The ropes should remain taut to maintain the correct amount of force on the affected limb. Loosening the ropes could disrupt the alignment and effectiveness of the traction, leading to inadequate treatment or further injury.

Choice D Reason:
Maintaining a specific weight for skin traction, such as 6.8 kg (15 lb), is a prescribed action based on the client's condition and the physician's orders. However, the exact weight to be used is determined by the healthcare provider and may vary from case to case. The nurse's role is to ensure that the prescribed weight is accurately maintained.

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Correct Answer is B

Explanation

Choice A reason:
Pinning the tubing to the client's bed sheets is not recommended as it can cause tension on the tube, potentially leading to dislodgement or damage to the tube. The tubing should be secured in a manner that allows some mobility without causing undue stress on the chest tube insertion site.

Choice B reason:
Replacing the unit when the drainage chamber is full is essential to maintain the functionality of the closed-chest tube drainage system. A full drainage chamber can prevent further collection of fluid or air, compromising the system's ability to maintain negative pressure in the pleural space, which is necessary for lung re-expansion.

Choice C reason:
Clamping the tube for 30 minutes every 6 hours is not a standard practice and could be dangerous. Clamping a chest tube without a physician's order or not in preparation for removal can lead to tension pneumothorax, especially if the patient has ongoing air leaks.

Choice D reason:
Monitoring for at least 150 mL of drainage every hour is not a specific action that should be taken. The amount of drainage should be monitored, but there is no standard amount that applies to all patients. Excessive drainage should be reported, as it may indicate hemorrhage or other complications.

A. Bleach B. Chlorhexidine C. Isopropyl alcohol D. Hydrogen peroxide

Correct Answer is A

Explanation

Choice A Reason:
Bleach is a widely recommended disinfectant for cleaning blood spills, especially in healthcare settings. The CDC suggests using a 1:10 dilution of household bleach with water to effectively kill pathogens present in blood spills. This solution should be applied to the affected area and allowed to air dry for at least 10 minutes to ensure proper disinfection.

Choice B Reason:
Chlorhexidine is an antiseptic agent more commonly used for skin disinfection before medical procedures rather than for cleaning environmental surfaces. While it has antimicrobial properties, it is not the preferred choice for cleaning blood spills as it may not be as effective as bleach in eliminating all potential pathogens.

Choice C Reason:
Isopropyl alcohol, while a good disinfectant for certain applications, is not the best option for cleaning blood spills. It does not have the same broad-spectrum killing power as bleach and may not be effective against all the pathogens that could be present in blood, particularly in a setting where a client has AIDS.

Choice D Reason:
Hydrogen peroxide is another common household disinfectant. However, it is generally less effective than bleach for cleaning blood spills. It may not kill all types of pathogens, especially in the concentrations typically available over the counter.

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