The nurse is assigned to care for a client in traction. The nurse creates a plan of a care for the client and would include which action in the pian?

Remove the traction when the client wants to ambulate

Provide pin site care for skin traction.

Check the weights to ensure that they are hanging freely

Adjust the amount of weight depending on the clients preference

Answer and Explanation

The Correct Answer is C

A) Remove the traction when the client wants to ambulate:
Traction is a therapeutic treatment used to immobilize bones, joints, or soft tissues, often after fractures or orthopedic procedures. Removing traction to allow ambulation is not appropriate unless directed by a healthcare provider. Traction must be maintained to ensure proper alignment and healing of the affected body part. Premature removal can cause complications such as malalignment, delayed healing, or further injury.

B) Provide pin site care for skin traction:
Pin site care is required for skeletal traction, not skin traction. Skin traction uses adhesive strips or other external devices to apply force to the body, and no pins are involved. Skeletal traction, on the other hand, uses pins, screws, or wires that are inserted directly into the bone. It’s important to provide proper pin site care to prevent infection in skeletal traction, but this is not relevant to skin traction, which doesn’t involve direct penetration of the skin.

C) Check the weights to ensure that they are hanging freely:
It is essential to check that the weights in traction are hanging freely and not in contact with the floor or any other surface. Weights should be unobstructed to provide continuous, even force that maintains the proper alignment of the injured body part. Any obstruction or improper positioning of the weights can compromise the effectiveness of the traction and delay healing.

D) Adjust the amount of weight depending on the client’s preference:
The amount of weight used in traction is determined by the healthcare provider based on the specific injury or condition being treated. Adjusting the weight based on the client's preference could lead to inappropriate tension, worsening the injury or hindering the healing process. The nurse should not adjust the weight without a physician’s order, as it is critical to follow the prescribed treatment plan for optimal healing and safety.

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Correct Answer is A

Explanation

A. "Promptly change out of wet clothing such as bathing suits after use":
This is a key recommendation for preventing urinary tract infections (UTIs), especially in women. Wet clothing, such as swimsuits or damp exercise clothes, creates a warm, moist environment that encourages bacterial growth, particularly in the genital and perineal areas. Changing out of wet clothing promptly helps reduce the risk of bacteria entering the urinary tract, which is an important preventive measure for recurrent UTIs.

B. "Buy synthetic underwear rather than cotton fabric":
This statement is incorrect. Cotton underwear is recommended because it is breathable and helps keep the genital area dry, reducing the likelihood of bacterial growth. Synthetic fabrics, on the other hand, trap moisture and heat, creating an environment where bacteria can thrive, increasing the risk of UTIs. Therefore, wearing cotton underwear is advised rather than synthetic fabric.

C. "Be sure to empty your bladder every 6-8 hours":
This recommendation is somewhat inaccurate. To prevent UTIs, it is essential to empty the bladder more frequently than every 6-8 hours, especially if the person feels the urge to urinate. Holding urine for long periods can increase the risk of bacterial growth in the urinary tract. It is generally recommended to urinate at least every 3-4 hours during the day to prevent urine stagnation and reduce the risk of infection.

D. "Try to drink 500-1000 ml of fluid per day":
This fluid intake recommendation is too low. To prevent UTIs, a higher fluid intake is necessary—typically 2-3 liters (2000-3000 mL) of fluid per day. Adequate hydration helps ensure frequent urination, which flushes out bacteria from the urinary tract. Consuming only 500-1000 mL of fluid per day is insufficient and would likely increase the risk of UTIs due to less frequent urination and less flushing of the urinary system.

A. Western Blot test B. Initiation of broad-spectrum antibiotics C. Initiation of Isoniazid and Rifampin D. Antiretroviral therapy.

Correct Answer is B

Explanation

A) "Western Blot test":
. The Western Blot test is typically used to confirm HIV infection after a positive enzyme-linked immunosorbent assay (ELISA). This test is not relevant for diagnosing pneumonia, which is the most likely cause of this patient's symptoms. The patient's presentation — including dyspnea on exertion, cough with green sputum, fever, fatigue, and bilateral consolidation on the chest X-ray — points to a respiratory infection (likely pneumonia) rather than an HIV-related issue.

B) "Initiation of broad-spectrum antibiotics":
. The patient's symptoms, including dyspnea, cough with green sputum, fever, fatigue, and bilateral consolidation on chest X-ray, strongly suggest community-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP). In either case, broad-spectrum antibiotics are indicated to cover a wide range of potential bacterial pathogens, especially in older adults or those with comorbidities who may be at risk for more severe infections. Immediate treatment with antibiotics is necessary to prevent complications such as respiratory failure or sepsis. Once cultures and sensitivities are obtained, the antibiotics may be adjusted based on the specific pathogen.

C) "Initiation of Isoniazid and Rifampin":
. Isoniazid and Rifampin are used to treat tuberculosis (TB), but this patient’s symptoms do not indicate TB. The patient is experiencing acute respiratory symptoms, including fever, cough with sputum production, and consolidation on chest X-ray, which are more indicative of pneumonia than of tuberculosis. Although TB could present similarly, additional testing such as a TB skin test (TST) or sputum culture for acid-fast bacilli (AFB) would be necessary before initiating antitubercular therapy. The priority intervention here is antibiotic treatment for bacterial pneumonia.

D) "Antiretroviral therapy":
. Antiretroviral therapy (ART) is used to treat HIV, but there is no indication that this patient has HIV. The symptoms presented — dyspnea, productive cough, fever, and bilateral consolidation on chest X-ray — are more consistent with an acute bacterial infection such as pneumonia rather than an HIV-related complication. ART would only be appropriate if the patient were known to have HIV and developed an opportunistic infection; however, this patient's presentation suggests a primary respiratory infection, not an HIV-related issue.

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The nurse is assigned to care for a client in traction. The nurse creates a plan of a care for the client and would include which action in the pian?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating a female client about reducing the recurrence of urinary tract infections. Which of the following statements should pre nurse make?

Correct Answer is A

Explanation

An older adult client presents with dyspnea on exertion, cough with green sputum, fever, and fatigue. The nurse notes thick rhonchi/coarse crackles upon lung auscultation and the patient's chest X-ray shows bilateral consolidation. The nurse anticipates which of the following interventions?

Correct Answer is B

Explanation

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