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 C
Explanation
A. "Take the vital signs on all the patients in the lounge and tell me whether there are problems." This instruction is vague and lacks specific information about what "problems" to look for, which may lead to inconsistent reporting.
B. "Do the morning care first on the patients in 205 and 206 who can't get out of bed." This instruction is clear, but it does not specify important details like the specific type of care expected or additional needs.
C. "Give the patient in 204A a shower after breakfast, and call me to check her feet before you get her dressed." This instruction is specific, clear, and provides a follow-up action (check her feet) which is necessary. It allows the nursing assistant to understand exactly what to do and when.
D. "You take care of all the patients in 205 and 206. Let me know how you're doing and whether you need any help." This instruction lacks specificity and does not outline clear tasks or expectations, which may lead to confusion.
Correct Answer is D
Explanation
A. While bowel sounds can indicate gastrointestinal activity, they do not directly correlate with pain management or the underlying cause of abdominal discomfort in chronic pancreatitis.
B. The level and amount of physical activity may impact overall well-being but are less directly related to the management of abdominal pain from pancreatitis.
C. The color and consistency of feces can provide some information regarding pancreatic function and fat absorption but is not the most immediate factor affecting pain management.
D. Understanding the client’s eating patterns, including food triggers and timing, is crucial because certain foods can exacerbate abdominal pain in chronic pancreatitis. Dietary adjustments can significantly help manage symptoms and improve quality of life.