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 B
Explanation
The correct answer is B.
Initiate droplet precautions. The rationale is that RSV is a highly contagious viral infection that causes respiratory tract inflammation and can spread through respiratory droplets from coughing or sneezing. The nurse should wear a mask and gloves when caring for the preschooler and isolate them from other children to prevent transmission.
Correct Answer is C
Explanation
The correct answer is choice C. Clean the stoma using an inward to outward circular motion.
Choice A rationale:
Cleansing the inner cannula with isopropyl alcohol is not recommended because it can be irritating to the mucosa. Instead, the inner cannula should be cleaned with sterile saline or a prescribed solution.
Choice B rationale:
Preparing sterile supplies after removing the inner cannula is not the correct sequence. Sterile supplies should be prepared before starting the procedure to maintain sterility and efficiency.
Choice C rationale:
Cleaning the stoma using an inward to outward circular motion is correct because it helps to prevent the spread of microorganisms from the outer skin to the stoma site, reducing the risk of infection.
Choice D rationale:
Ensuring at least three finger widths of space under tracheostomy ties is incorrect. The correct practice is to ensure that only one to two finger widths can fit under the tracheostomy ties to ensure they are secure but not too tight.
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