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 A
Explanation
A. Selecting another finger is the best action to prevent discomfort and ensure an accurate blood sample. The reddened and engorged tip may indicate that milking the finger caused bruising or altered blood flow, which can affect the glucose reading.
B. Applying pressure to the site may be appropriate after collecting a sample, but it does not address the issue of obtaining an accurate sample from an engorged finger.
C. Assessing radial pulse volume is not relevant in this situation and does not address the problem at hand.
D. Collecting the blood sample from a reddened and engorged finger could yield an inaccurate result, so it is better to select a different finger.
Correct Answer is B
Explanation
A. Limiting oral fluid intake may be necessary in some cases of glomerulonephritis, especially if the client is experiencing edema or hypertension, but this is not a universal recommendation and should be assessed individually.
B. Restricting protein intake is important for clients with glomerulonephritis to reduce the workload on the kidneys and prevent further damage. This is a critical dietary adjustment that nurses should emphasize.
C. Increasing potassium-rich foods can be contraindicated in clients with glomerulonephritis, especially if renal function is compromised, as it can lead to hyperkalemia.
D. While high-fiber foods can be beneficial for overall health, they do not directly address the specific dietary needs of a client with glomerulonephritis in terms of protein and electrolyte balance.