Which nursing intervention is appropriate for a client with skeletal traction?

Pin site care

Five-pound weight lifting restriction

Prone positioning

Intermitent weights

Answer and Explanation

The Correct Answer is A

Choice A reason: Pin site care is essential for a client with skeletal traction to prevent infection and ensure proper healing.

Choice B reason: A five-pound weight lifting restriction is not related to the care of a client with skeletal traction.

Choice C reason: Prone positioning is not typically recommended for clients with skeletal traction as it may interfere with the traction setup.

Choice D reason: Intermitent weights are not a standard intervention for skeletal traction, which requires consistent and controlled application of force.

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Correct Answer is D

Explanation

Choice A reason: Lethargy implies a state of sluggishness, drowsiness, or fatigue, not the inability to respond to stimuli.

Choice B reason: Stupor refers to a state of near-unconsciousness or insensibility, but the patient may respond to vigorous stimulation.

Choice C reason: Obtundation describes a state of consciousness characterized by a reduced alertness and a slow response to stimuli, but not complete unresponsiveness.

Choice D reason: Comatose is the correct term for a state of deep unconsciousness in which a patient cannot be aroused, fitting the description of the patient's condition.

A. As soon as the nurse can prepare the client and the administration set B. 2 hours after obtaining blood from the blood bank C. When the client has finished eating his Burger King lunch D. When the client states he is ready to start the infusion

Correct Answer is A

Explanation

Choice A reason: Packed RBCs should be transfused as soon as possible once the nurse has prepared everything necessary for the transfusion.

Choice B reason: Waiting 2 hours after obtaining the blood is not necessary and could delay needed treatment.

Choice C reason: The client's mealtime should not delay the transfusion of blood, which is a time-sensitive medical treatment.

Choice D reason: While the client's readiness is important, it should not unduly delay the transfusion if the client is medically stable and the transfusion is necessary.

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Which nursing intervention is appropriate for a client with skeletal traction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 11:30. The nurse should begin the infusion at which of the following times?

Correct Answer is A

Explanation

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