A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?
Assess the pulses proximal to the fracture site.
Assess the pin sites for signs of infection.
Administer pain medication at designated intervals around the clock.
Remove traction every shift and provide skin care.
The Correct Answer is A
A. Assessing the pulses proximal to the fracture site is crucial for evaluating blood circulation to the affected limb and detecting potential complications such as compartment syndrome.
B. While monitoring pin sites for signs of infection is important, the priority is ensuring adequate circulation.
C. Administering pain medication is essential for comfort but does not address potential complications from skeletal traction.
D. Removing traction every shift is not advisable as it can compromise the alignment and healing of the fracture.
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Correct Answer is B
Explanation
A. Bronze pigmentation is often associated with venous insufficiency rather than arterial compromise.
B. Compromised peripheral arterial circulation can lead to decreased blood flow, resulting in uneven or diminished hair distribution on the lower extremities due to lack of nourishment to hair follicles.
C. Lower leg edema is more commonly associated with venous insufficiency rather than arterial insufficiency.
D. A bounding peripheral pulse indicates increased arterial pressure or volume, which is not consistent with compromised arterial circulation, where pulses are typically weak or absent.
Correct Answer is D
Explanation
A. While safe sex practices can significantly reduce the risk of STIs, they do not eliminate the risk entirely, especially with multiple partners involved.
B. This statement is misleading; not all STIs are transmitted solely through sexual intercourse, as some can also be transmitted through non-sexual means.
C. It is important to recognize that asymptomatic individuals can still be carriers of STIs; thus, this statement may provide false reassurance.
D. Teaching the client about the importance of following the medication regimen and attending follow-up appointments is critical for effective treatment of gonorrhea and preventing further transmission or complications. This approach prioritizes the client’s health and reinforces the need for responsible sexual practices.