When providing care to a client in skeletal traction, what action would be included in the nurse's plan of care?

Provide cast care to bilateral lower extremities

Institute measures to prevent skin breakdown

Clean the pins every hour with peroxide to prevent infection

Place client on contact precautions

Maintain proper alignment and position of the traction

Answer and Explanation

The Correct Answer is E

Choice A reason: Providing cast care to bilateral lower extremities is not an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is not relevant to the type of traction. Skeletal traction involves the insertion of pins, wires, or screws into the bone, and does not require a cast. Cast care is more applicable to clients in plaster or fiberglass casts.

Choice B reason: Instituting measures to prevent skin breakdown is an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is a potential complication of prolonged immobilization and pressure. The nurse should inspect the skin regularly, change the bed linens frequently, use pressure-relieving devices, and encourage the client to shift positions as much as possible.

Choice C reason: Cleaning the pins every hour with peroxide to prevent infection is not an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is excessive and harmful. The nurse should follow the facility's protocol for pin site care, which usually involves cleaning the pins once or twice a day with a mild antiseptic solution, such as chlorhexidine or saline. Peroxide is not recommended, as it can damage the tissue and delay the healing.

Choice D reason: Placing the client on contact precautions is not an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is not indicated for this type of traction. Contact precautions are used for clients who have infections that can be transmitted by direct or indirect contact, such as MRSA, VRE, or C. difficile. Skeletal traction does not pose a high risk of infection, unless there is a pin site infection or osteomyelitis.

Choice E reason: Maintaining proper alignment and position of the traction is an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is essential for the effectiveness and safety of the traction. The nurse should ensure that the traction is applied correctly, that the weights are hanging freely, that the ropes are not twisted or frayed, and that the pulleys are not obstructed. The nurse should also avoid lifting or moving the weights, as it can alter the traction force and cause complications.

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Correct Answer is E

Explanation

Choice A reason: Including an average daily intake of 300 mg of calcium is not a sufficient measure to prevent osteoporosis, as it is below the recommended dietary allowance (RDA) for calcium, which is 1000 mg for adults aged 19-50 years, and 1200 mg for adults aged 51 years and older. Calcium is an essential mineral for bone health, as it helps to build and maintain the bone density and strength.

Choice B reason: Walking 20-30 minutes three days a week is not an optimal measure to prevent osteoporosis, as it is below the recommended physical activity guidelines, which suggest at least 150 minutes of moderate-intensity aerobic exercise per week, and at least two sessions of muscle-strengthening activities per week. Physical activity is beneficial for bone health, as it stimulates the bone formation and reduces the bone loss.

Choice C reason: Engaging in isometric exercise 20-30 minutes weekly is not an effective measure to prevent osteoporosis, as it is not the best type of exercise for bone health, and it is not performed frequently enough. Isometric exercise is a form of exercise that involves contracting the muscles without moving the joints, such as holding a plank or a wall sit. Isometric exercise does not provide enough mechanical stress or load to the bones, which is needed to stimulate the bone remodeling and growth.

Choice D reason: Including adequate intake of vitamin E is not a relevant measure to prevent osteoporosis, as it is not a major nutrient for bone health, and it has no direct effect on the bone metabolism. Vitamin E is an antioxidant that helps to protect the cells from oxidative stress and inflammation, which may have some indirect benefits for the bone health, but it is not a key factor. Vitamin E is also not a common deficiency, and it can be obtained from various foods, such as vegetable oils, nuts, seeds, and green leafy vegetables.

A. Corticosteroids B. Resting the affected extremity C. Applying ice D. Massage E. Compression dressings

Correct Answer is B

Explanation

Choice A reason: Corticosteroids are not a common treatment modality for contusions, strains, or sprains. They are anti-inflammatory drugs that may be used for chronic conditions such as arthritis, asthma, or allergies, but they have side effects such as weakening the immune system, increasing the risk of infection, and delaying wound healing.

Choice B reason: Resting the affected extremity is a common treatment modality for contusions, strains, or sprains. It helps to reduce pain, swelling, and inflammation, and to prevent further injury or damage to the tissues.

Choice C reason: Applying ice is a common treatment modality for contusions, strains, or sprains, but only for the first 24 to 48 hours after the injury. It helps to reduce pain, swelling, and inflammation by constricting the blood vessels and decreasing the blood flow to the injured area. After 48 hours, heat may be applied to increase the blood flow and promote healing.

Choice D reason: Massage is not a common treatment modality for contusions, strains, or sprains. It may be beneficial for some chronic musculoskeletal conditions, but it should be avoided for acute injuries as it may increase the pain, swelling, and inflammation by stimulating the blood flow and aggravating the damaged tissues.

Choice E reason: Compression dressings are a common treatment modality for contusions, strains, or sprains. They help to reduce pain, swelling, and inflammation by applying pressure to the injured area and limiting the movement of the tissues. They also provide support and stability to the affected extremity.

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When providing care to a client in skeletal traction, what action would be included in the nurse's plan of care?

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Naxlex Comprehensive Predictor Exams

Which should the nurse include when instructing a client on the prevention of osteoporosis?

Correct Answer is E

Explanation

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Correct Answer is B

Explanation

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