A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

The client develops a life-threatening situation.

The client needs to have an x-ray of the femur performed.

The client complains of pain.

The client has to be repositioned in the bed.

Answer and Explanation

The Correct Answer is A

A. In the event of a life-threatening situation, the immediate priority is to address the situation to stabilize the client's condition. If removing the weights from the traction device is necessary to manage the life-threatening situation then the nurse may remove the weights as part of the overall management of the client's care.

B. It's generally not necessary to remove the weights from the traction device for an x-ray of the femur. Instead, the x-ray can typically be performed with the weights in place.

C. Pain management is important for clients in traction, but removing the weights is not the initial action for addressing pain. The nurse should assess the cause of the pain and intervene appropriately.

D. Repositioning the client in the bed may be necessary for comfort, preventing pressure ulcers, or facilitating care activities. When repositioning the client, the nurse should ensure that the traction setup remains intact and that the weights are properly secured.

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Correct Answer is ["A","D"]

Explanation

A. The heart rate has increased from 92/min on Day 1 to 108/min on Day 2. This significant increase warrants immediate follow-up as it may indicate pain, anxiety, or an underlying physiological issue such as hemorrhage, infection, or cardiac complications.

D. The temperature has increased from 36.4°C (97.5°F) on Day 1 to 37.2°C (98.9°F) on Day 2. While this increase is within a relatively normal range, it is approaching a fever range (> 38°C or 100.4°F) and warrants further evaluation to determine if there is an underlying infection or inflammation.

B. The oxygen saturation remains relatively stable, from 95% on Day 1 to 96% on Day 2. While it is important to monitor oxygen saturation, the minimal change does not indicate an immediate concern. However, it should still be monitored closely for any further decrease.

C. Edema is not directly mentioned in the provided data. While edema can be indicative of various health issues, there is no evidence in the given information to suggest its presence or severity as a concern requiring immediate follow-up.

E. Urine color is not provided in the given data. While changes in urine color can indicate dehydration or other health issues, it is not mentioned in the assessment findings and therefore not a factor for immediate follow-up based on the information provided.

F Pedal pulses were noted as +2 on Day 1, indicating that they were present and normal. Unless there is a significant change in pedal pulses or signs of vascular compromise, such as decreased or absent pulses, there is no immediate need for follow-up based on the given information.

A. Explain the discharge instructions to the client and parents. B. Apply an ice pack to the casted leg. C. Perform a neurovascular assessment. D. Provide reassurance to the client and parents.

Correct Answer is C

Explanation

C. A neurovascular assessment involves evaluating the circulation, sensation, and movement of the limb distal to the cast to ensure there are no signs of neurovascular compromise, such as decreased pulses, numbness, tingling, or weakness. Prompt identification of any neurovascular impairment is essential for preventing complications such as compartment syndrome.

A. Explaining discharge instructions is important for ensuring the client and their parents understand how to care for the cast at home. However, it is not the priority action.

B. Applying an ice pack to the casted leg can help reduce swelling and provide pain relief, but it is not the priority action immediately after the cast application.

D. Providing reassurance is important for alleviating anxiety and promoting a positive experience for the client and their parents. However, it is not the priority action.

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A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department (ED). Exhibits Select the 4 assessment findings on day 2 that require immediate follow-up.

Correct Answer is ["A","D"]

Explanation

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Correct Answer is C

Explanation

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