Question

The nurse is serving as preceptor to a new nurse on the orthopedic unit. Which action by the new nurse requires intervention? A. Asking the client with a cast on the leg to move the toes B. Checking and documenting the weight amounts on the client's with traction C. Assisting with a bed change on a client with traction by removing and replacing the linen top to bottom D. Helping a family member get a client with a prosthetic hip into a straight chair

Short answer

A. Asking the client with a cast on the leg to move the toes B. Checking and documenting the weight amounts on the client's traction C. Assisting with a bed change on a client with traction by removing and replacing the linen top to bottom D. Helping a family member get a client with a prosthetic hip into a straight chair Answer: C. Assisting with a bed change on a client with traction by removing and replacing the linen top to bottom is the action that requires intervention.

Step-by-step solution

Understand the options

Read the given options and understand the nursing actions described in each.

Determine the consequences of each action

Consider the effects each action might have on the clients, and if any of them would require intervention due to the potential harm or inconvenience they could cause.

Compare the options

Compare the four actions and determine which of the actions requires intervention, while the others are desirable or acceptable.

Select the correct answer

Based on the analysis, choose the answer that best describes the action that requires intervention. From the analysis, we can determine the following consequences: A. Asking the client with a cast on the leg to move the toes is good practice as it promotes circulation, helps identify potential issues early, and doesn't require intervention. B. Checking and documenting the weight amounts on the client's traction is essential for monitoring purpose and doesn't require intervention. C. Assisting with a bed change on a client with traction by removing and replacing the linen top to bottom is incorrect, as it's important to change linens side-to-side instead. This action requires intervention. D. Helping a family member get a client with a prosthetic hip into a straight chair is acceptable and doesn't require intervention as long as the nurse ensures that the client is safely positioned. Therefore, the correct answer is C. Assisting with a bed change on a client with traction by removing and replacing the linen top to bottom is the action that requires intervention.

Key concepts

Nursing Interventions

In preparing for the NCLEX-RN exam, understanding nursing interventions is pivotal, particularly when it comes to effective care and management of patients. Nursing interventions include a wide array of actions, from assessing patient needs to implementing and evaluating their care.

For instance, in an orthopedic setting, asking the patient to move their toes (Option A) or checking and documenting weight for traction (Option B) are both viable nursing interventions that promote patient well-being. These actions are proactive steps that ensure the patient's condition is continuously assessed and any deviations from the expected recovery process are noted promptly.

It's important for students to recognize that such interventions are not merely routine; they are critical components of patient care that can significantly impact outcomes. Through repetitive practice and careful study of various interventions, students can cultivate the keen judgment needed to deliver exceptional care.

Orthopedic Nursing Care

Orthopedic nursing care is a specialized field focusing on the treatment and management of patients with skeletal system issues. One key aspect of orthopedic nursing is the proper handling of patients with traction or those who have undergone joint replacement surgery.

Our textbook exercise illustrates a common scenario—a bed change for a patient under traction. It's crucial to understand that the correct method is a side-to-side approach to maintain alignment and avoid disrupting the traction setup. The exercise solution (Option C) importantly highlights the need for intervention when this is not followed, as this mistake can lead to complications such as tissue injury or impaired circulation.

Necessary Adjustments for Patients in Traction

When caring for patients with traction, nur ses must always be aware of the positioning and tension in the traction system. Adjusting linens and ensuring that weights are hanging freely are interventions that maintain traction's effectiveness and patient safety.

Patient Safety in Nursing

Patient safety is the cornerstone of nursing practice and permeates every aspect of care. Comprehensive knowledge and implementation of safety measures are non-negotiable in preparing for the NCLEX-RN exam.

The exercise presents several actions but highlights one (Option C) that compromises patient safety—incorrectly changing bed linens for a patient in traction. Such an action could not only lead to physical harm for the patient but also undermines the very essence of orthopedic nursing care, which is to stabilize and support skeletal integrity.

Patient safety in nursing expands beyond the immediate task at hand, encompassing a holistic approach to prevent harm. Examples include creating a safe environment, educating patients and family members, and meticulously following protocols for mobilization and equipment use. Prospective nurses must integrate these concepts into their practice to ensure they are fully prepared to provide care in a manner that prioritizes patient safety above all else.