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 D
Explanation
A. Encouraging physical activity, such as walking, is important for cardiovascular health, but it is not a measurable outcome related to the client's current condition of blurred vision and cardiovascular disease.
B. While educating the family about signs and symptoms is valuable, it does not directly address the client's health status or outcomes that can be measured.
C. A target blood pressure of less than 160/90 mm Hg does not adequately control hypertension and may still pose a risk to cardiovascular health, especially given the blurred vision, which could indicate possible complications.
D. Setting a goal for the client’s daily blood pressure to be less than 140/80 mm Hg is a clear, measurable outcome that indicates effective management of hypertension and promotes overall cardiovascular health. This target is aligned with current clinical guidelines for hypertension management.
Correct Answer is B
Explanation
A. "Don't worry, I'm sure your son will visit."
This response is dismissive and assumes that the son will visit, which may not be the case. It may come across as insensitive.
B. "Your son hasn't been around much lately?"
This response reflects the patient's statement, encouraging them to elaborate. It shows empathy and gives the patient space to express their feelings.
C. "My son doesn't come to visit me either."
This response shifts focus away from the patient and may make them feel that their concern is trivialized.
D. "How terrible that he doesn't visit you."
This response is judgmental and might make the patient feel worse or lead them to think the nurse disapproves of their son.