Nokea
A nurse cares for a client in skeletal traction. The nurse notes that the skin around the client's pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next?
- A. Request a prescription to decrease the traction weight.
- B. Apply a warm compress to reduce swelling.
- C. Cleanse the area twice, scrubbing off the crusty areas.
- D. Obtain a prescription to culture the drainage.
Correct Answer: D
Rationale: These clinical manifestations indicate inflammation and possible infection. Obtaining a prescription to culture the drainage is the appropriate action to identify and treat a potential infection. Decreasing traction weight or scrubbing the area could exacerbate the issue, and a warm compress may not address the underlying infection.
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A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.)
- A. Edema "? Increased capillary permeability
- B. Pallor "? Increased blood flow to the area
- C. Unequal pulses "? Increased production of lactic acid
- D. Cyanosis "? Anaerobic metabolism
- E. Tingling "? A release of histamine
Correct Answer: A,C,D
Rationale: Clinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, unequal pulses are caused by increased production of lactic acid, and cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, not increased blood flow, and tingling is caused by increased tissue pressure, not histamine release.
A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities should the nurse include in this client's teaching? (Select all that apply.)
- A. Frequently assess the ergonomics of the equipment being used.
- B. Take breaks to stretch fingers and wrists during working hours.
- C. Perform wrist exercises to strengthen muscles.
- D. Adjust activities to increase pain and swelling in wrists.
- E. Use wrist splints during repetitive tasks.
Correct Answer: A,B,C,E
Rationale: To prevent carpal tunnel syndrome, the nurse should teach the client to assess the ergonomics of their workspace, take breaks to stretch fingers and wrists, perform wrist exercises to strengthen muscles, and use wrist splints during repetitive tasks. Adjusting activities to increase pain and swelling would worsen the condition and should not be recommended.
A nurse cares for a client with a fracture injury. Twenty minutes after an opioid pain medication is administered, the client reports pain in the site of the fracture. Which actions should the nurse take? (Select all that apply.)
- A. Administer additional opioids as prescribed.
- B. Elevate the extremity on pillows.
- C. Apply ice to the fracture site.
- D. Apply heat to the fracture site.
- E. Keep the extremity in a dependent position.
Correct Answer: A,B,C
Rationale: The client with a new fracture likely has edema; elevating the extremity and applying ice will help in decreasing pain and swelling. Administration of additional opioids within dosage guidelines may be ordered. Heat and dependent positioning will increase edema and potentially worsen pain.
A nurse plans care for a client who is prescribed skeletal traction. Which intervention should the nurse include in this plan of care to decrease the client's risk for infection?
- A. Wash the traction lines and sockets once a day.
- B. Release traction tension for 30 minutes twice a day.
- C. Do not place the traction weights on the floor.
- D. Schedule for pin care to be provided every shift.
Correct Answer: D
Rationale: To decrease the risk for infection in a client with skeletal traction or external fixation, the nurse should provide routine pin care and assess manifestations of infection at the pin sites every shift. The traction lines and sockets are external and do not come in contact with the client's skin, so these do not need to be washed. Releasing traction tension requires a prescription, and placing weights on the floor does not directly decrease infection risk.
Which action should the nurse take to ensure proper traction management?
- A. Inspect the client's skin when performing a bed bath.
- B. Apply oxygen by nasal cannula.
- C. Provide pin care by using alcohol wipes to clean the sites.
- D. Ensure that the weights remain freely hanging at all times.
Correct Answer: D
Rationale: Traction weights should be freely hanging at all times. They should not be lifted manually or allowed to rest on the floor. The client should remain in traction during hygiene activities. The nurse should assess the client's skin and provide pin and wound care for a client who is in traction; this should not be delegated to the UAP.