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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Palpating the femoral pulse is an essential part of assessing the neurovascular status of a client with a femur fracture. The presence and strength of the femoral pulse can indicate adequate blood flow to the lower extremity.

B. While measuring the circumference of the thigh can provide some information about swelling or changes in the size of the limb, it does not directly assess neurovascular status.

C. Monitoring the client's calf for edema is important for assessing for signs of deep vein thrombosis (DVT) or venous insufficiency, but it is not the primary technique for assessing neurovascular status.

D. Instructing the client to wiggle his toes is a way to assess motor function and nerve function, which is part of the neurovascular assessment. However, it is not the initial step in assessing neurovascular status in a client with an unrepaired femur fracture. The femoral pulse should be assessed first to ensure adequate blood flow.

A. "You will need to fast for 12 hours before the test." B. "You will need to lie flat for 4 hours following the test." C. "You will need to remove all jewelry before the test." D. "You will need to empty your bladder before the test."

Correct Answer is C

Explanation

A. Fasting is not necessary for a dual-energy x-ray absorptiometry (DXA) scan, as it does not involve ingesting anything.

B. The client does not need to lie flat for an extended period following a DXA scan. They can resume normal activities immediately after the test.

C.The nurse should instruct the client to remove all jewelry or metal objects that can interfere with the test. A DXA scan is the mostly commonly used screening and diagnostic tool for measuring bone mineral density.

D. . It is not necessary to empty the bladder before the test.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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