A nurse is caring for a client who has a fractured hip and is in Buck's traction prior to surgical repair. What should the nurse include in the plan of care?
Perform a neurovascular assessment of the extremity daily
Assess the client's skin condition under the boot weekly
Increase the traction if the client complains of increased pain
Ensure that the traction weights do not touch the floor
The Correct Answer is D
Choice A reason: Performing a neurovascular assessment of the extremity daily is not enough. The nurse should perform this assessment every 2 to 4 hours to monitor for signs of impaired circulation or nerve function.
Choice B reason: Assessing the client's skin condition under the boot weekly is not enough. The nurse should assess the skin under the boot at least once a day to prevent skin breakdown and infection.
Choice C reason: Increasing the traction if the client complains of increased pain is not appropriate. The nurse should not adjust the traction without a provider's order. Increasing the traction could cause more damage to the fracture site or the surrounding tissues.
Choice D reason: Ensuring that the traction weights do not touch the floor is the correct action. The nurse should make sure that the weights are hanging freely and not resting on anything. This ensures that the traction is applied continuously and evenly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Staphylococcus aureus is the most common pathogen to cause osteomyelitis, as it is a gram-positive bacterium that can invade the bone through the bloodstream, a wound, or a surgical site. It can cause acute or chronic inflammation and infection of the bone and bone marrow.
Choice B reason: Escherichia coli is not the most common pathogen to cause osteomyelitis, as it is a gram-negative bacterium that is usually found in the gastrointestinal tract. It can cause urinary tract infections, diarrhea, or sepsis, but it is not a frequent cause of bone infections.
Choice C reason: Proteus mirabilis is not the most common pathogen to cause osteomyelitis, as it is a gram-negative bacterium that is usually found in the urinary tract. It can cause urinary tract infections, kidney stones, or septicemia, but it is not a common cause of bone infections.
Choice D reason: Pseudomonas aeruginosa is not the most common pathogen to cause osteomyelitis, as it is a gram-negative bacterium that is usually found in moist environments. It can cause skin infections, pneumonia, or septic shock, but it is not a frequent cause of bone infections.
Choice E reason: None of the above is not a correct choice, as there is one option that matches the most common pathogen to cause osteomyelitis.
Correct Answer is C
Explanation
Choice A reason: Diet is not a priority assessment for a client with osteoarthritis, as it is not a direct cause or consequence of the condition. However, diet may play a role in the management of osteoarthritis, as it can affect the body weight, inflammation, and nutrition of the client.
Choice B reason: Skin surrounding the affected joint is not a priority assessment for a client with osteoarthritis, as it is not a common or serious complication of the condition. However, skin may be affected by the use of heat or cold therapy, topical medications, or joint braces, which may cause irritation, dryness, or infection.
Choice C reason: Pain is a priority assessment for a client with osteoarthritis, as it is the main symptom and the most distressing aspect of the condition. Pain can affect the client's quality of life, mobility, function, and mood. The nurse should assess the location, intensity, frequency, duration, and aggravating or relieving factors of the pain, and provide appropriate interventions to relieve the pain.
Choice D reason: Capillary refill of affected extremity is not a priority assessment for a client with osteoarthritis, as it is not a typical or significant finding of the condition. However, capillary refill may be affected by the circulation, temperature, or hydration of the client, which may influence the healing and recovery of the joint.
Choice E reason: Range of motion of affected joint is not a priority assessment for a client with osteoarthritis, but an important assessment to evaluate the function and mobility of the joint. Osteoarthritis can cause stiffness, swelling, and deformity of the joint, which can limit the range of motion and impair the activities of daily living. The nurse should assess the active and passive range of motion of the joint, and encourage the client to perform regular exercises to maintain the joint health.
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