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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Nitroglycerin tablets should not be refilled every 12 months without consulting a healthcare provider. The potency of nitroglycerin tablets can decrease over time, and they should be replaced every 6 months.
Choice B Reason:
Storing nitroglycerin in the refrigerator is not recommended. The medication should be kept at room temperature, away from light and moisture, and in its original container to maintain its stability and potency.
Choice C Reason:
Sublingual nitroglycerin tablets should not be swallowed whole with a glass of water. They are designed to be dissolved under the tongue to provide rapid relief from chest pain.
Choice D Reason:
This is the correct instruction. If chest pain is not relieved after taking the first sublingual nitroglycerin tablet, it is standard practice to take a second tablet after 5 minutes. If the pain persists after three doses taken 5 minutes apart, emergency medical attention is required.
Correct Answer is B
Explanation
Choice A reason:
Running wires and cords under carpeting is not recommended as it poses a tripping hazard and can also lead to wear on the cords, which could cause electrical fires. It's important to keep cords and wires secured and out of walkways to prevent falls, which are a leading cause of injury among older adults.
Choice B reason:
Placing white tape on the edges of stairs is a safety measure that can help prevent falls by increasing the visibility of each step. This is particularly useful for older adults who may have vision impairments. Enhanced visibility of stair edges can significantly reduce the risk of missteps and falls.
Choice C reason:
While having the furnace inspected regularly is important for maintaining a safe home environment, doing so every 2 years may not be sufficient. It is generally recommended to have heating systems inspected annually to ensure they are functioning properly and to prevent carbon monoxide poisoning.
Choice D reason:
Placing area rugs on wooden floors can create a tripping hazard, especially if the rugs do not have a non-slip backing. It's better to secure rugs with double-sided tape or slip-resistant backings, or to avoid them altogether in high-traffic areas to maintain a safe walking surface.
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