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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Disposes of contaminated sheets in a linen bag: Contaminated linens should be placed in a designated leak-proof bag, often specifically marked for contaminated items. Simply disposing of them in a regular linen bag without proper precautions could lead to the spread of infection.
B. Wears clean gloves when performing oral hygiene: Wearing clean gloves during oral care is an effective and appropriate use of supplies to maintain standard precautions and protect both the client and the caregiver from potential contamination.
C. Empties the sharps container when it is full: The sharps container should be emptied when it is three-quarters full, not completely full. Waiting until it is full increases the risk of needlestick injuries and improper disposal practices.
D. Wears an N95 mask when bathing a client who has Clostridium difficile: For Clostridium difficile, the appropriate personal protective equipment includes gloves and a gown, not an N95 mask. C. difficile is transmitted via contact with spores, not through airborne particles.
Correct Answer is A
Explanation
- Allergies: The client has a documented allergy to penicillin, and cefazolin is a first-generation cephalosporin. Cephalosporins have a similar beta-lactam structure to penicillins, and there is a potential risk of cross-reactivity. Administering cefazolin without provider clearance could result in a severe allergic reaction or anaphylaxis.
- Temperature: Although the client's temperature is elevated at 39.3° C (102.8° F), this is an expected finding in pneumonia and does not need to be reported before antibiotic administration. In fact, treating the infection may help reduce the fever.
- Chest x-ray: The chest x-ray showing left lower lobe density is consistent with a diagnosis of pneumonia and supports the need for antibiotic treatment. This finding confirms the infection in the lungs and guides the choice of antibiotic therapy. It is not a reason to withhold the prescribed medication but rather a justification for it.
- WBC count: The client’s WBC count is elevated at 16,000/mm³, which is typical in bacterial infections like pneumonia. It reflects the body's immune response and further supports the need for antibiotics rather than delaying them.
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