Nokea
A nurse cares for a client placed in skeletal traction. The client asks, What is the primary purpose of this type of traction? How should the nurse respond?
- A. This traction will prevent fat aligning your fractured bone.
- B. This traction will prevent future complications and back pain.
- C. Traction decreases muscle spasms that occur with a fracture.
- D. This type of traction minimizes damage as a result of fracture treatment.
Correct Answer: A
Rationale: Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a secondary benefit, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage, but these are not the primary purposes of skeletal traction.
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These symptoms represent early warning signs of acute compartment syndrome. Which action should the nurse take first?
- A. Assess the pedal pulses.
- B. Apply oxygen by nasal cannula.
- C. Increase the IV flow rate.
- D. Loosen the traction.
Correct Answer: A
Rationale: These symptoms represent early warning signs of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesia precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible. Vital signs need to be obtained to determine if oxygen and intravenous fluids are necessary. Traction, if implemented, should never be loosened without a provider's prescription.
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.
A nurse assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess?
- A. Stability to maintain abduction of the affected arm for more than 90 seconds.
- B. Shoulder pain that is relieved with overhead stretches and at night.
- C. Inability to initiate or maintain abduction of the affected arm at the shoulder.
- D. Referred pain to the shoulder and arm opposite the affected shoulder.
Correct Answer: C
Rationale: Clients with a rotator cuff tear are unable to initiate or maintain abduction of the affected arm at the shoulder. This is known as the drop arm test. The client should not have difficulty with adduction of the arm, nor experience pain relief with overhead stretches. Pain is usually more intense at night and with related activities, and referred pain to the opposite shoulder is not typical.
A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this client's pain?
- A. Administer meperidine every 4 hours around the clock.
- B. Patient-controlled analgesia (PCA) pump with morphine.
- C. Ibuprofen (Motrin) 600 mg orally every 4 hours PRN for pain.
- D. Morphine 2 mg intravenous push every 4 hours PRN for pain.
Correct Answer: B
Rationale: The older adult client should not be treated with meperidine because toxic metabolites can cause seizures. A PCA pump with morphine is the best option for controlling pain in this client. Ibuprofen may not provide sufficient pain relief for multiple fractures, and PRN morphine may not maintain consistent pain control.
A nurse cares for a client who had a long-leg cast applied last week. The client states, 'I cannot seem to catch my breath and I feel a bit light-headed.' Which action should the nurse take next?
- A. Auscultate the client's lung fields anteriorly and posteriorly.
- B. Administer oxygen via nasal cannula.
- C. Check the client's oxygen saturation.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: Shortness of breath and light-headedness in a client with a long-leg cast may indicate a pulmonary embolism, a serious complication possibly related to fat embolism syndrome from the fracture. Notifying the healthcare provider immediately is the priority to ensure rapid evaluation and treatment. Auscultation, oxygen administration, and checking oxygen saturation are secondary actions that may follow after the provider is notified.