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 D
Explanation
Choice A reason:
The face is incorrect: Facial skin colour can vary for many reasons, but it may not be the best indicator of jaundice in individuals with dark skin.
Choice B reason
Shoulders is incorrect: The shoulders are not typically indicative of jaundice.
Choice C reason:
Palm of the hands is incorrect: While the palm of the hands can sometimes show yellowing in cases of jaundice, it is less reliable than observing the sclera.
Choice D reason:
Sclera is the best location. In individuals with darker skin tones, yellowish discoloration of the skin due to jaundice can be more challenging to detect. However, the sclera of the eyes can still show noticeable yellowing, making it a reliable location for assessing jaundice in individuals with both light and dark skin.
Correct Answer is C
Explanation
Tucking the glove cuffs under the gown sleeves can prevent contamination of clothing and skin by microorganisms that may be present on the gown or gloves.
The nurse should apply the gown after washing hands and before putting on gloves, and tie it securely at the neck and waist.
The nurse should not push up the gown sleeves, as this can expose skin and clothing to contamination.
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