A nurse is caring for an adolescent client whose right leg is in Buck's traction. Which of the following interventions should the nurse implement to promote the client's mobility?

Active range-of-motion exercises of the left leg

Log rolling every 2 hr

Passive range of motion to the right leg

Isometric exercises of both legs

Answer and Explanation

The Correct Answer is D

A. Active range-of-motion exercises of the left leg promote mobility in the unaffected limb but do not fully address the need for maintaining muscle strength in both legs.

B. Log rolling every 2 hours is a technique used for clients who require spinal precautions or have limited movement due to back injuries. It does not promote mobility for a client in Buck's traction.

C. Passive range of motion to the right leg may prevent joint stiffness but does not actively maintain or improve muscle strength. Additionally, movement of the affected limb should be minimized to maintain the alignment of the traction.

D. Isometric exercises of both legs are appropriate for promoting mobility and maintaining muscle strength without disrupting the traction. These exercises involve contracting the muscles without moving the joints, which is safe for the affected limb in Buck's traction.

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Correct Answer is B

Explanation

A. Rhonchi are low-pitched, coarse sounds heard during both inspiration and expiration. They are typically associated with mucus or secretions in the larger airways and do not match the description of high-pitched squeaking sounds.

B. Wheezes are high-pitched, continuous sounds heard primarily during expiration. They result from narrowed airways, which are characteristic of asthma. The description provided matches wheezes, making this the correct documentation.

C. Stridor is a high-pitched sound heard predominantly during inspiration and is associated with upper airway obstruction. It does not match the description of sounds heard during exhalation.

D. Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli or smaller airways. They do not match the high-pitched squeaking sounds described.

A. Pulmonary embolism B. Fat embolism syndrome C. Acute compartment syndrome D. Malignant hypothermia

Correct Answer is C

Explanation

A. Pulmonary embolism typically presents with symptoms such as shortness of breath, chest pain, and hypoxia, not localized edema in the calf.

B. Fat embolism syndrome (FES) is associated with symptoms like respiratory distress, confusion, petechial rash, and hypoxemia, but not specifically with increasing edema in the calf.

C. Acute compartment syndrome occurs when increased pressure within a muscle compartment leads to decreased blood flow, causing swelling, pain, and possible tissue damage. This is a medical emergency, and the increasing edema in the calf is a common sign of this condition.

D. Malignant hypothermia is a rare reaction to certain anesthetic agents, leading to symptoms like muscle rigidity, hyperthermia, and tachycardia. It does not cause localized edema in the calf.

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A nurse is caring for an adolescent client whose right leg is in Buck's traction. Which of the following interventions should the nurse implement to promote the client's mobility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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