img-download-app
img-download-app

The nurse is caring for a patient who requires skeletal traction after a back injury. Which of the following are appropriate nursing interventions?

Explanation

• When injury involves fracture-dislocation of the cervical spine, cervical tongs like Crutchfield tongs may be used for skeletal traction to achieve alignment and immobilization.

• To ensure effectiveness, the nurse should maintain traction at all times. Failing to maintain traction can cause further damage to the fractured bone and surrounding tissue.

• A skin assessment should be performed whenever the patient is repositioned (which should be at least every 2-3 hours) due to risk of skin breakdown from ischemia and compression of tissue when immobilized.

• Pin sites are susceptible to infection, so the sites should be assessed for increased redness, swelling, pain, or drainage.

• The traction weights should never be supported; they need to hang freely in order to be effective.

• Stool softeners should be administered to prevent postoperative constipation and obstruction.

Visit our website for other NCLEX topics now!
Related questions

The nurse is providing teaching to a client with newly-diagnosed heart failure. Which description(s) of heart failure should the nurse include? 

A nurse is using the Braden scale to assess a patient's risk for pressure ulcer formation. The patient's sensory perception is slightly limited, she is occasionally moist, she is chairfast, her mobility is slightly limited, nutrition is adequate, and friction is a potential problem. What is this patient's risk?

A nurse is caring for a patient with a diagnosed bundle branch block. Which specific electrocardiogram (EKG) lead location will determine whether the patient has a right- or left-bundle branch block?

A patient is diagnosed with contact dermatitis. The nurse explains to the patient that which of the following is the most likely cause?

A nurse is providing education to a patient recently diagnosed with psoriasis. Which of the following is not a component of typical psoriasis treatment?

A patient with a large facial spider angioma says to the nurse, "This thing is so ugly, why won't it go away?" How should the nurse respond?

A nurse on the medical surgical floor walked into a patient's room and found the patient lying face down on the floor, unresponsive to verbal stimulation. After the nurse calls for assistance, the next course of action should be which of the following?

A patient is intubated and placed on mechanical ventilation due to respiratory failure. Which of the following items is most important and should be kept next to the patient's bed at all times?

The nurse is caring for a patient diagnosed with shigellosis. Which of the following statements made by the patient indicates the need for additional medical counseling?

The nurse is providing discharge instructions to a patient with chronic obstructive pulmonary disease (COPD). The nurse should include instructions on breathing exercises that involve

A patient recently diagnosed with celiac disease wants to know more about what foods he should avoid. Which of the following should be included in the discharge instructions as a food to avoid?

A 57-year-old is admitted to an inpatient unit due to Crohn's disease. Which of the following should not be in the care plan?

A patient with emphysema is short of breath. The nurse instructs the patient to assume which of the following positions?

The nurse is caring for a patient with urolithiasis who is scheduled for a extracorporeal shock wave lithotripsy. The nurse would explain to the patient that:

The nurse is providing instructions to a patient with hemorrhoids. The nurse should recommend which of the following?

A patient with dark skin is experiencing respiratory distress due to an asthma exacerbation. The nurse assesses the patient for cyanosis by inspecting the

A nurse is caring for a client with gastroenteritis and is documenting the clinical manifestations indicating dehydration. What would indicate the patient is dehydrated?

The nurse is assessing a patient that underwent a unilateral adrenalectomy. To assess for hyperkalemia, the nurse should be alert for

A nurse is caring for a client diagnosed with testicular cancer who is receiving Cisplatin intravenously. The nurse monitors the client for a drug-drug interaction if which among the following are also administered?