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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Increasing daily fluid intake to 2 liters per day is not typically recommended for patients with acute glomerulonephritis and edema. In fact, fluid restriction is often necessary to manage edema and prevent fluid overload, which can exacerbate the condition.
Choice B reason: Prescribing an antifungal agent is not a standard treatment for acute glomerulonephritis unless there is a specific indication of a fungal infection, which is not commonly associated with this condition.
Choice C reason: While ambulation is generally good for overall health, recommending a specific frequency of ambulation in the halls three times daily without considering the patient’s overall condition and mobility is not appropriate. The level of activity should be tailored to the individual’s tolerance and clinical status.
Choice D reason: Decreasing sodium intake is a key recommendation for patients with acute glomerulonephritis, especially when edema is present. Sodium restriction helps to manage fluid retention and reduce swelling. It is also beneficial for controlling blood pressure, which can be elevated in this condition.
Correct Answer is ["E"]
Explanation
Choice A Reason:
Allowing the affected area to remain open to air is not the best practice for managing burns. While it's important not to cover the burn with tight or adhesive dressings, the area should be covered with a clean, dry cloth to protect it from further injury and contamination.
Choice B Reason:
Running cool water over the affected area is recommended for minor burns. This helps to cool the burn, reduce pain, and prevent further tissue damage. The water should be cool, not cold, as extremely cold temperatures can cause further damage to the affected tissue.
Choice C Reason:
Maintaining skin integrity over the blisters is important, but this choice is incomplete. Blisters should not be intentionally ruptured, as they provide a natural barrier to infection. If a blister does break, the area should be cleaned gently, and an antibiotic ointment may be applied before covering with a sterile dressing.
Choice D Reason:
Applying ice directly to the burn is not recommended. Ice can cause further damage to the burned skin and may lead to frostbite. Instead, only cool water should be used as mentioned in choice B.
Choice E Reason:
Administering ibuprofen for pain is appropriate for a minor burn. Ibuprofen can help reduce inflammation and alleviate pain. However, it's important to ensure that the client has no contraindications to ibuprofen, such as allergies or stomach ulcers.
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