A nurse is assisting in caring for a client who is in Buck's traction. Which of the following actions should the nurse take?

Ensure the weights are hanging freely.

Maintain the elevation of the head of the bed.

Check the client's skin twice daily for manifestations of breakdown.

Monitor capillary refill once per day.

Answer and Explanation

The Correct Answer is A

Buck’s traction is a type of skin traction used to immobilize and align fractures of the lower extremity, commonly the hip or femur. It relies on a constant pulling force to maintain proper bone alignment and reduce muscle spasms. Proper application and maintenance are essential to ensure therapeutic effectiveness and prevent complications such as neurovascular compromise or skin injury. Nursing care focuses on maintaining traction alignment, monitoring circulation, and ensuring safety of the system.

Rationale:
A. Ensuring the weights are hanging freely is essential because traction depends on continuous, uninterrupted pulling force. If weights rest on the floor or bed, the traction force is disrupted, which can lead to loss of alignment and ineffective treatment. Free-hanging weights maintain consistent tension on the affected limb for proper bone stabilization.

B. Maintaining elevation of the head of the bed is not a priority specific to Buck’s traction. Slight elevation may be used for comfort or respiratory support, but it does not directly impact the effectiveness of traction. The key priority is maintaining proper alignment and ensuring the weights remain unobstructed.

C. Checking the client’s skin twice daily for breakdown is important but not the most immediate priority in traction management. Skin integrity should be assessed regularly, especially under straps and bony prominences, but ensuring correct traction setup takes precedence to maintain therapeutic effectiveness.

D. Monitoring capillary refill once per day is insufficient because neurovascular checks in traction clients should be performed more frequently. Capillary refill, along with pulse, color, temperature, and sensation, should be assessed at least every few hours to detect early signs of impaired circulation or compartment syndrome.

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Correct Answer is B

Explanation

Clients who have experienced a stroke with right-sided hemiplegia have unilateral weakness and impaired motor control on the affected side. Safe transfer techniques are essential to prevent falls, injury, and caregiver strain. Proper positioning of assistive devices and use of the unaffected side improve stability during transfers. Nursing care focuses on promoting safety, maintaining body alignment, and encouraging as much client participation as possible.

Rationale:
A. Asking the client to reach around the nurse’s neck for support is unsafe because it places excessive strain on the nurse and does not provide stable support for the client. This technique increases the risk of injury to both the nurse and the client and does not follow proper transfer mechanics.

B. Placing the wheelchair on the left side of the client is correct because the left side is the unaffected side in right-sided hemiplegia. This allows the client to pivot and transfer using their stronger side, improving balance and reducing the risk of falls. Proper positioning of the wheelchair also ensures a safer and more controlled transfer process.

C. Pivoting the client on the foot closest to the chair is incorrect because the pivot should occur on the client’s stronger, unaffected side. In right-sided hemiplegia, the right side is weak, so weight-bearing and pivoting should be supported through the left side. Incorrect pivoting increases instability and fall risk.

D. Reaching under the client’s arms to pull them up is unsafe because it can cause shoulder injury, including subluxation or nerve damage, especially in stroke clients with flaccid limbs. This technique also does not promote proper body mechanics for the nurse or controlled movement for the client. Safe transfers require use of transfer belts or assistive devices rather than lifting under the arms.

A. Community-acquired pneumonia B. Paget's disease C. Herpes zoster D. Clostridioides difficile colitis

Correct Answer is B

Explanation

Clients receiving chemotherapy for Hodgkin’s lymphoma are highly immunocompromised due to bone marrow suppression, particularly neutropenia, which places them at high risk for infection. When a private room is unavailable, infection control principles guide appropriate roommate selection to minimize exposure to infectious pathogens. The safest roommate is one who does not have an infectious disease or transmissible condition. This reduces the risk of opportunistic infections in the immunosuppressed client.

Rationale:
A. Community-acquired pneumonia is an active respiratory infection that can be transmitted via droplets, making it unsafe for a severely immunocompromised client. Exposure could lead to severe or even life-threatening infection due to reduced immune defenses from chemotherapy. Therefore, this client should not be placed in the same room.

B. Paget’s disease is a noninfectious chronic bone disorder characterized by abnormal bone remodeling. It is not caused by pathogens and poses no risk of transmission to others. This is the safest option for roommate placement with an immunocompromised oncology client.

C. Herpes zoster is caused by reactivation of the varicella-zoster virus and is highly contagious through direct contact with lesions and airborne transmission in disseminated cases. Immunocompromised clients are at high risk for severe infection if exposed. This condition requires isolation precautions, making it inappropriate for shared room placement.

D. Clostridioides difficile colitis is a highly contagious gastrointestinal infection transmitted via spores through the fecal-oral route and contaminated surfaces. Immunocompromised clients are especially vulnerable to severe complications. Strict contact precautions are required, so sharing a room is contraindicated.

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A nurse is assisting in caring for a client who is in Buck's traction. Which of the following actions should the nurse take?

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