A nurse is collecting data from a client who is in Buck's traction. Which of the following findings indicates the traction is functioning correctly?

The weights apply a pulling force continuously.

The boot allows active leg movement.

The footplate rests against the foot of the bed.

The weights are just touching the floor.

Answer and Explanation

The Correct Answer is A

Rationale:

A. The weights apply a pulling force continuously: Buck’s traction is a form of skin traction used to immobilize fractures and reduce muscle spasms. The weights must hang freely and provide a constant pulling force to maintain alignment and promote healing.

B. The boot allows active leg movement: In Buck’s traction, the affected leg should be immobilized. Active movement would interfere with the consistent traction force and compromise the effectiveness of the treatment.

C. The footplate rests against the foot of the bed: The client’s foot should not press against the bedframe or footplate, as this can counteract the traction force and cause improper alignment. There should be adequate space for traction to be effective.

D. The weights are just touching the floor: Weights should hang freely and never touch the floor. If they rest on the floor, the traction force is lost, defeating the purpose of the setup and potentially leading to complications.

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Correct Answer is D

Explanation

Rationale:

A. Hypertension: Hypertension is not typically associated with an allergic reaction to vancomycin. Hypotension may occur in severe reactions like "red man syndrome," but elevated blood pressure is generally unrelated to allergic responses.

B. Headache: Headache is a possible side effect of many medications, including vancomycin, but it does not specifically indicate an allergic reaction. It is a nonspecific symptom and usually does not warrant discontinuation unless severe.

C. Tinnitus: Tinnitus is a sign of ototoxicity, a known adverse effect of vancomycin, especially with high doses or prolonged use. However, it is not indicative of an allergic reaction but rather toxicity affecting the auditory system.

D. Urticaria: Urticaria, or hives, is a classic manifestation of an allergic reaction involving histamine release causing itchy, raised, red skin lesions. Its presence during vancomycin administration signals hypersensitivity and requires immediate attention.

A. Increased urinary output B. Temperature 38.2° С (100.0° F) C. Presence of lochia serosa D. Deep tendon reflexes 3+

Correct Answer is A

Explanation

Rationale:

A. Increased urinary output: Diuresis is expected within the first 12 to 24 hours postpartum as the body eliminates excess fluid retained during pregnancy. Increased urinary output helps reduce blood volume and interstitial fluid accumulated during gestation, making this a normal finding.

B. Temperature 38.2° C (100.0° F): A slight elevation in temperature can occur postpartum due to dehydration or breast engorgement, but 38.2°C is at the upper limit and may suggest infection if persistent. Therefore, it should be monitored rather than considered a typical finding.

C. Presence of lochia serosa: At 12 hours postpartum, lochia rubra, which is bright red and contains blood and tissue debris, is expected. Lochia serosa, which is pink or brown and more serous, typically appears around day 4 postpartum.

D. Deep tendon reflexes 3+: Reflexes of 3+ are slightly brisker than normal and may indicate neurological irritability or preeclampsia if seen with other symptoms. A normal postpartum reflex should be 2+, so this finding requires further evaluation.

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A nurse is collecting data from a client who is in Buck's traction. Which of the following findings indicates the traction is functioning correctly?

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