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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason:

Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.

Choice B reason:

Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag

Choice C reason:

Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.

Choice D reason

Infuse 500 ml lactated Ringer's IV.This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.

A. Being honest with the parents of a child about the need to report suspected abuse B. Keeping a promise to visit with a client who is housebound after the delivery of care C. Accepting the decision of an older adult client to live alone in her home D. Ensuring that a client who is homeless receives preventive medical

Correct Answer is D

Explanation

Choice A reason:

Being honest with the parents of a child about the need to report suspected abuse is not the correct option. This option involves honesty and ethical responsibility but does not pertain to the fair distribution of resources or benefits.

Choice B reason

Keeping a promise to visit with a client who is housebound after the delivery of care is not the appropriate option. While keeping promises is an ethical principle, it is not related to the fair distribution of resources or benefits.

Choice C reason:

Accepting the decision of an older adult client to live alone in her home is not the correct option. Respecting a client's autonomy and right to make decisions about their living arrangements is an ethical principle, but it is not directly related to distributive justice.

Choice D reason:

The ethical principle of distributive justice is about fair and equitable distribution of resources and benefits within a society or group. It emphasizes providing equal access to services and resources to all individuals, especially those who are vulnerable or marginalized. In this context, the nurse demonstrates distributive justice by ensuring that a homeless client receives preventive medical care, which means they are being provided with necessary health resources and services that might otherwise be challenging for them to access due to their disadvantaged situation.

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