A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

"Russell's traction uses a sling under the knee to treat a fracture of the femur."

"Russell's traction uses a cervical halter to decrease cervical muscle spasms."

"Russell's traction uses skeletal pins to stabilize the fracture."

"Russell's traction uses a pelvic girdle belt to decrease lower back pain."

Answer and Explanation

The Correct Answer is A

The nurse should tell the newly licensed nurse that Russell's traction uses a sling under the knee to treat a fracture of the femur. Russell's traction is a type of skin traction that is used to immobilize and align a fractured femur. It involves placing a sling under the knee and applying weights to the aﬀected leg to provide continuous traction.

Russell's traction does not use a cervical halter, skeletal pins, or a pelvic girdle belt. A cervical halter is used to treat neck injuries. Skeletal pins are used in skeletal traction to stabilize fractures. A pelvic girdle belt is used to treat lower back pain.

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Correct Answer is C

Explanation

To prevent autonomic dysreﬂexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreﬂexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back¹. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest¹. One way to lower the chance of complications is to use the bathroom on a regular schedule and keep the bladder and bowels from becoming too full.

a. Monitoring for elevated blood pressure is important but not an intervention to prevent autonomic dysreﬂexia.
b. Providing analgesia for headaches is important but not an intervention to prevent autonomic dysreﬂexia.
d. Elevating the client's head is important but not an intervention to prevent autonomic dysreﬂexia.

A. Insert a padded tongue blade into the client's mouth. B. Keep the client in a supine position. C. Gently restrain the client's extremities. D. Place a pillow under the client's head.

Correct Answer is D

Explanation

The nurse should place a pillow under the client's head if the client is on the ﬂoor in the clonic phase of a tonic-clonic seizure. This can help protect the client's head from injury during the seizure.

Inserting a padded tongue blade into the client's mouth, keeping the client in a supine position, and gently restraining the client's extremities are not appropriate interventions for the nurse to take in this situation. Inserting a padded tongue blade into the client's mouth can cause injury to the teeth and gums. Keeping the client in a supine position can increase the risk of aspiration. Gently restraining the client's extremities can cause injury and is not recommended during a seizure.

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A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreﬂexia. Which of the following interventions should the nurse take to prevent autonomic dysreﬂexia?

Correct Answer is C

Explanation

A nurse enters a client's room and finds the client on the ﬂoor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

A nurse is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands these therapies?

A nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. Which of the following actions should the nurse take?

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