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
The correct answer is D. Limiting the number of choices for the client who has Alzheimer's disease can help reduce confusion and frustration and promote independence and dignity. Using written signs to assist the client with locating the bathroom may not be helpful, as the client may have difficulty reading or remembering what they mean. Using confrontation to manage the client's behavior can increase agitation and aggression and worsen cognitive decline. Providing a stimulating environment for the client can also overwhelm and overstimulate them and cause sensory overload.
Correct Answer is ["A","B","C","F"]
Explanation
The nurse is responsible for educating the client and their partner about advance directives and facilitating their decision-making process. Advance directives are legal documents that allow the client to express their preferences for medical care and treatments at the end of life.
They also enable the client to appoint a health care proxy, who is a person who can make health care decisions for the client if they are unable to do so themselves.
The nurse should provide the client with written information about advance directives, document that the provider discussed do-notresuscitate status with the client, and communicate advance directives status via the medical record and shift report.
The nurse should not instruct the client that an advance directive is a legal document and must be honored by care providers, as this may imply coercion or limit the client's right to change their mind.
The nurse should also not inform the client that an advance directive discontinues further care, as this is inaccurate and may discourage the client from completing one.
The nurse should facilitate a power of attorney for health care document only if the client wishes to designate a health care proxy.
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