A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction. Which of the following actions should the nurse take?

Apply a 9 kg 120 lb weight to the traction

Clean the pin insertion sites on a daily basis.

Remove the weights while the client is eating

Ensure that the weights are hanging freely.

Answer and Explanation

The Correct Answer is D

A. Apply a 9 kg (20 lb) weight to the traction: Buck’s traction is designed for short-term immobilization and uses lighter weights, typically between 2 to 5 kg (4.5 to 10 lb). Applying 9 kg (20 lb) would be excessive and could lead to nerve damage, impaired circulation, or additional injury.

B. Clean the pin insertion sites on a daily basis: Buck’s traction is a type of skin traction, not skeletal traction, and does not involve pins inserted into the bone. Therefore, there are no pin sites to clean in Buck’s traction, making this action irrelevant for the client’s care.

C. Remove the weights while the client is eating: Weights should never be removed or lifted unless there is a provider’s specific order to do so. Interrupting the continuous pull of the traction can cause misalignment of the fracture and delay healing.

D. Ensure that the weights are hanging freely: It is essential that the weights in Buck’s traction hang freely without resting on the floor or bed. This ensures a constant, steady pull on the extremity, which helps maintain proper alignment and promotes effective immobilization.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E","F","G","H"]

Explanation

Temperature 35.3°C (95.5°F): Hypothermia following surgery is concerning because it may reflect poor perfusion, internal bleeding, or shock. Immediate warming measures and evaluation are necessary to prevent further deterioration.
Blood pressure 90/60 mm Hg: The client’s blood pressure is lower than previous values and indicates potential hypovolemia or ongoing blood loss. Hypotension post-surgery must be urgently addressed to avoid progression to shock.
Skin cool and moist to touch: Cool, moist skin is an early clinical sign of decreased tissue perfusion and shock. When found alongside hypotension and hypothermia, it suggests that circulatory compromise may already be developing.
Moderate amount of sanguineous drainage noted on lower dressing: Moderate bleeding post-laparoscopic surgery is abnormal. This finding, in combination with hypotension and other signs of poor perfusion, strongly suggests possible internal bleeding requiring urgent provider notification.
Hypoactive bowel sounds: Hypoactive bowel sounds are expected after abdominal surgery due to anesthesia and reduced gut motility. They are not an immediate sign of a critical complication unless accompanied by abdominal distension or severe pain, they should however be monitored.
Heart rate 60/min: A heart rate of 60/min is at the lower limit of normal. Although 60/min is still technically within normal range, the trend of decreasing heart rate from baseline 90 beats/min, especially in the setting of hypotension and signs of poor perfusion, is concerning. This decline may indicate worsening hemodynamic status and must be monitored closely for further deterioration..
Pedal pulse +1 bilateral: Diminished pedal pulses (+1) indicate reduced peripheral circulation. In isolation, it may not be critical, but when combined with hypotension and cool skin, it becomes part of the overall picture suggesting decreased perfusion and should be monitored carefully.

A. Explain the rounding schedule to the client B. Tell the client about the visiting hours C. Review meal options with the client. D. Place the call light within reach of the client.

Correct Answer is D

Explanation

A. Explain the rounding schedule to the client: While explaining the rounding schedule helps reassure the client that frequent checks will occur, it does not immediately address safety needs. Immediate actions to reduce fall risk are prioritized before providing routine information.

B. Tell the client about the visiting hours: Informing the client about visiting hours is part of general orientation but is not critical to preventing falls. Safety interventions must be implemented first to minimize risk of injury as soon as possible upon admission.

C. Review meal options with the client: Discussing meal options is part of admission and planning for nutrition, but it is not an urgent action to ensure the client's immediate safety, particularly when there is a known risk for falls.

D. Place the call light within reach of the client: Ensuring the call light is within reach allows the client to easily request assistance before attempting to move independently. This simple action is a high-priority intervention to prevent falls and promote immediate client safety.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","D","E","F","G","H"]

Explanation

A nurse is admitting a client who is at risk for falls. Which of the following actions is the nurse's priority?

Correct Answer is D

Explanation

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