Free NCLEX-RN Exam Braindumps (page: 255)

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Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90-90 skeletal traction with a pin in the distal end of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:

  1. The nurse may lift only the weights that are applying traction in order to reposition him in bed
  2. The client will need special skin care at the pin site according to hospital policy or the physician's preference
  3. The traction pull should result in an immediate increase in comfort and reduce the need for pain medication
  4. The client should be discouraged from participating in self-care activities to avoid the risk of disrupting the traction

Answer(s): B

Explanation:

(A) Skeletal traction, including the weights that are applying the traction, is never released by the nurse. (B) It is necessary to keep the pin site clean and free from infection. (C) When first placed in traction, the client may experience increased discomfort as a result of the traction pull fatiguing the muscle. (D) When the child in traction is allowed to participate in his care, it gives him a measure of control and helps him to cope with the situation.



Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90-90 skeletal traction with a pin in the distal end of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:

  1. The nurse may lift only the weights that are applying traction in order to reposition him in bed
  2. The client will need special skin care at the pin site according to hospital policy or the physician's preference
  3. The traction pull should result in an immediate increase in comfort and reduce the need for pain medication
  4. The client should be discouraged from participating in self-care activities to avoid the risk of disrupting the traction

Answer(s): B

Explanation:

(A) Skeletal traction, including the weights that are applying the traction, is never released by the nurse. (B) It is necessary to keep the pin site clean and free from infection. (C) When first placed in traction, the client may experience increased discomfort as a result of the traction pull fatiguing the muscle. (D) When the child in traction is allowed to participate in his care, it gives him a measure of control and helps him to cope with the situation.



A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.
What tests should the nurse anticipate?

  1. Reticulocyte count, creatinine phosphokinase (CPK)
  2. Aspartate transaminase, alanine transaminase
  3. Sedimentation rate, WBC count
  4. Lactic dehydrogenase, CPK

Answer(s): D

Explanation:

(A) Reticulocyte count measures the number of immature erythrocytes. CPK is an enzyme released from injured myocardial tissue. (B) Aspartate transaminase is an enzyme released from injured myocardial tissue. Alanine transaminase is an enzyme released for general tissue destruction, which is specific for liver injury. (C) Sedimentation rate is a nonspecific test for inflammation. (D) Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.



A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.
What tests should the nurse anticipate?

  1. Reticulocyte count, creatinine phosphokinase (CPK)
  2. Aspartate transaminase, alanine transaminase
  3. Sedimentation rate, WBC count
  4. Lactic dehydrogenase, CPK

Answer(s): D

Explanation:

(A) Reticulocyte count measures the number of immature erythrocytes. CPK is an enzyme released from injured myocardial tissue. (B) Aspartate transaminase is an enzyme released from injured myocardial tissue. Alanine transaminase is an enzyme released for general tissue destruction, which is specific for liver injury. (C) Sedimentation rate is a nonspecific test for inflammation. (D) Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.



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