A nurse is caring for a client who has a femur fracture with the leg in Buck's traction. Which of the following actions should the nurse take?
Remove the weights for 20 min for the client's report of severe pain.
Position the knot of the rope at the top of the pulley
Apply 6.8 kg (15 lb) of weight for use in traction
Compare bilateral pedal pulses.
The Correct Answer is D
The correct answer is D. Compare bilateral pedal pulses.
Rationale: The nurse should compare bilateral pedal pulses to assess for adequate circulation and perfusion to the lower extremities. Buck's traction is a type of skin traction that is widely used for broken femurs and hips, as well as fractures in the socket portion of the "ball-and-socket" hip joint (acetabular fractures). It uses splints, bandages, and adhesive tapes to position a limb near the fracture, then weights and pulleys are attached and pressure is applied. The nurse should not remove the weights for 20 min for the client's report of severe pain, as this would disrupt the alignment and traction of the fracture .
The nurse should not position the knot of the rope at the top of the pulley, as this would interfere with the smooth movement of the rope and reduce the effectiveness of traction. The nurse should not apply 6.8 kg (15 lb) of weight for use in traction, as this would exceed the recommended weight limit for skin traction and could cause skin damage or nerve injury. The weight should not exceed 4.5 kilograms at any point.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Explanation: The nurse should prioritize seizures as the most serious and life-threatening finding in a client who is experiencing acute alcohol withdrawal. Seizures can occur within 48 hours of cessation of alcohol intake and can lead to status epilepticus, brain damage, or death. Tachycardia, cramping, and elevated temperature are also common signs of alcohol withdrawal, but they are not as urgent as seizures.
Correct Answer is B
Explanation
The correct answer is B.
Information regarding client health can be e-mailed if encrypted. The nurse should follow the Health Insurance Portability and Accountability Act (HIPAA) guidelines to protect client privacy and confidentiality. According to HIPAA, health information can be transmitted electronically if it is encrypted or otherwise secured.
Unwanted printed health information should be shredded or disposed of in a secure bin, not a trash can. Members of a healthcare team should not share a computer password or leave a computer unattended when accessing client information. A client has the right to access his own medical records and request amendments or corrections.
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