Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client returns to the surgical unit from the PACU in skeletal traction. The nurses should take action to correct. Which of the following problems with the traction setup?
A. The weights rest against the foot of the bed.
If a client returns to the surgical unit from the PACU in skeletal traction and the weights rest against the foot of the bed, the nurse should take action to correct this problem with the traction setup. The weights should be hanging freely and not touching any part of the bed or floor. This ensures that the traction is providing the appropriate amount of force to the affected limb. The other options listed are not problems with the traction setup. The ropes should be in the center of the wheel grooves, the weights should be equal on each side, and the ropes should attach securely to the pin.
B. The ropes are in the center of the wheel grooves.
C. The weights are equal on each side.
D. The ropes atach securely to the pin
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Full Explanation
If a client returns to the surgical unit from the PACU in skeletal traction and the weights rest against the foot of the bed, the nurse should take action to correct this problem with the traction setup. The weights should be hanging freely and not touching any part of the bed or floor. This ensures that the traction is providing the appropriate amount of force to the affected limb.
The other options listed are not problems with the traction setup. The ropes should be in the center of the wheel grooves, the weights should be equal on each side, and the ropes should attach securely to the pin.
Similar Questions
A nurse is contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?
A. Promote independence in activities of daily living for the client.
Promoting independence in activities of daily living for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.
B. Provide relief from pain and discomfort for the client.
Providing relief from pain and discomfort for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.
C. Maintain immobilization and alignment for the client.
When contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture, the highest priority nursing intervention to assist in meeting this outcome is to maintain immobilization and alignment for the client. This helps to ensure that the bones are in the correct position to heal properly and can prevent complications such as malunion or nonunion.
D. Provide optimal nutrition and hydration for the client.
Providing optimal nutrition and hydration for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.
Full Explanation
When contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture, the highest priority nursing intervention to assist in meeting this outcome is to maintain immobilization and alignment for the client. This helps to ensure that the bones are in the correct position to heal properly and can prevent complications such as malunion or nonunion.
a. Promoting independence in activities of daily living for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.
b. Providing relief from pain and discomfort for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.
d. Providing optimal nutrition and hydration for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.
A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreflexia. Which of the following actions should the nurse take first?
A. Raise the head of the bed.
If a nurse is caring for a client who has a spinal cord injury and suspects that the client has autonomic dysreflexia, the first action the nurse should take is to raise the head of the bed. This can help to lower the client's blood pressure and reduce the risk of complications such as stroke.
B. Check the client for a fecal impaction.
Checking the client for a fecal impaction is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
C. Check the client's bladder for distention.
Checking the client's bladder for distention is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
D. Ensure the room temperature is warm.
Ensuring that the room temperature is warm is not a priority intervention for a client who has autonomic dysreflexia.
Full Explanation
If a nurse is caring for a client who has a spinal cord injury and suspects that the client has autonomic dysreflexia, the first action the nurse should take is to raise the head of the bed. This can help to lower the client's blood pressure and reduce the risk of complications such as stroke.
b. Checking the client for a fecal impaction is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
c. Checking the client's bladder for distention is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
d. Ensuring that the room temperature is warm is not a priority intervention for a client who has autonomic dysreflexia.
A nurse in an urgent care centre is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)
A. Apply a compression bandage to the client's ankle.
B. Apply heat to the client's ankle.
C. Encourage range of motion of the client's foot.
D. Elevate the client's foot.
E. Check the client's toes for color, temperature, and sensation.
Full Explanation
These are the correct interventions that the nurse should take. Applying a compression bandage to the client's ankle can help reduce swelling and provide support to the injured area. Elevating the client's foot can also help reduce swelling by promoting venous return. Checking the client's toes for color, temperature, and sensation is important to assess for any potential nerve or vascular damage.
Applying heat to the client's ankle is not recommended as it can increase swelling and inflammation. Encouraging range of motion of the client's foot is also not recommended as it can cause further injury to the affected area.