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.
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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Related Questions
Correct Answer is C
Explanation
C. The patient's calf being swollen and warm to touch is concerning for a possible deep vein thrombosis (DVT), a clot formation in the deep veins of the leg. DVT is a serious complication post-surgery that requires immediate attention to prevent the clot from dislodging and causing a pulmonary embolism (PE), which can be life-threatening.
A. Abdominal pain after a total abdominal hysterectomy is common and can be expected due to the surgical incision and manipulation of abdominal tissues.
B. Fluid balance is important postoperatively to prevent complications like dehydration or fluid overload. A significant imbalance, with intake substantially greater than output, could indicate issues which may require intervention. However, this is not as urgent as a client with likely DVT.
D. A slight increase in temperature is common in the immediate postoperative period due to the body's response to tissue injury. While it could indicate infection, it's not necessarily alarming on its own.
Correct Answer is B
Explanation
B. If the patient expresses confusion or uncertainty about the surgical procedure, the nurse should notify the surgeon or appropriate healthcare provider promptly. The surgeon may need to revisit the discussion with the patient, clarify any misunderstandings, and answer any questions to ensure informed consent.
A. This option involves the nurse providing the patient with a comprehensive explanation of the planned surgical procedure, including the purpose, risks, benefits, and alternatives. That however, is the role of the provider.
C. While the operating room nurse may have knowledge about the planned surgical procedure, it is ultimately the responsibility of the surgeon or healthcare provider performing the procedure to ensure that the patient understands and consents to the surgery.
D. Administering preoperative antibiotics and managing sedative medications are important aspects of preoperative care but are not directly related to addressing the patient's concerns about understanding the planned surgical procedure.
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