A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)
Position weights against the foot of the bed,
Examine the skin under the traction splint.
Monitor peripheral pulses in the affected extremity.
Assess the temperature of the affected extremity.
just the prescribed weights every shift.
Correct Answer : B,C,D
A. Position weights against the foot of the bed: Incorrect. Weights in Buck's traction are typically hung freely over the end of the bed to provide the necessary countertraction. Placing them against the foot of the bed would not serve this purpose.
B. Examine the skin under the traction splint: Correct. It's important to regularly assess the skin underneath the traction splint to ensure there are no signs of pressure ulcers or skin breakdown.
C. Monitor peripheral pulses in the affected extremity: Correct. This is essential to ensure that blood flow to the extremity is not compromised by the traction.
D. Assess the temperature of the affected extremity: Correct. Monitoring the temperature helps in identifying any signs of impaired circulation.
E. Adjust the prescribed weights every shift: This is not something that should be done without specific orders from the healthcare provider. Adjusting the weights should be done based on the specific plan of care and provider's instructions.
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Related Questions
Correct Answer is C
Explanation
A. Remove the elastic bandage and re-wrap the stump once per day: This is not recommended. The elastic bandage provides support and helps reduce swelling. It should only be removed and re-wrapped as directed by the healthcare provider.
B. Secure the elastic bandage to the lowest joint: The bandage should be secure, but it should not be tied too tightly or secured directly over a joint. This could restrict blood flow and cause discomfort.
C. Wrap the stump with an elastic bandage in a figure-eight configuration: This is the correct action. A figure-eight configuration helps distribute pressure evenly, providing support and reducing the risk of edema and complications.
D. Perform passive range-of-motion exercises once daily: Range-of-motion exercises are important, but they should be performed within the parameters set by the healthcare provider. They should not be performed only once daily, and it's essential to avoid overexertion or straining the residual limb.
Correct Answer is ["32"]
Explanation
- To calculate the infusion rate, use the formula: mL/hr = (units/hr) x (mL) / (units) - Plug in the values from the question: mL/hr = (1600 units/hr) x (500 mL) / (25.000 units) - Simplify and solve: mL/hr = 32
- Round to the nearest whole number: 32
- The answer is 32 mL/hr
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