A nurse is planning care for a client who has a left hip fracture and is in Buck's traction. Which of the following interventions should the nurse include in the plan of care?

Inspect the skin under the boot every 8 hr.

Assess the client's peripheral circulation every 12 hr.

Ensure the weights are resting on the floor.

Remove the traction to allow the client to use the bathroom.

Answer and Explanation

The Correct Answer is A

A. Inspect the skin under the boot every 8 hr: Frequent skin assessment is critical for clients in Buck's traction because the traction boot or straps can cause pressure injuries, skin breakdown, or irritation. Checking the skin every 8 hours allows early detection of redness, sores, or areas of compromised circulation and prevents complications associated with prolonged immobility and pressure.

B. Assess the client's peripheral circulation every 12 hr: Peripheral circulation should be assessed more frequently than every 12 hours, typically every 1–2 hours initially, to detect early signs of neurovascular compromise such as cyanosis, pallor, coolness, or numbness. Waiting 12 hours could delay identification of circulation issues that may lead to tissue damage or compartment syndrome.

C. Ensure the weights are resting on the floor: Traction weights must hang freely to maintain proper alignment and effective traction. Allowing the weights to rest on the floor disrupts the pulling force, reducing traction effectiveness, increasing pain, and potentially worsening fracture displacement.

D. Remove the traction to allow the client to use the bathroom: Buck's traction should not be removed for routine activities such as toileting because interrupting traction can cause misalignment, increased pain, and delayed healing. Alternative methods, such as a bedside commode or urinal, should be used while maintaining traction integrity.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. High Fowler's: High Fowler’s position can assist with respiratory effort and comfort, but it does not specifically optimize cardiac output in a pregnant client. Upright positioning alone may not relieve pressure from the gravid uterus on major vessels.

B. Left lateral: Placing the client in the left lateral position relieves pressure of the uterus on the inferior vena cava and aorta, enhancing venous return to the heart and improving cardiac output. This position is especially important in clients with cardiac disease to reduce the risk of supine hypotensive syndrome and optimize maternal and fetal circulation.

C. Standing: Standing does not provide support for venous return and can increase the workload on the heart, potentially exacerbating cardiac compromise. It is not recommended for prolonged periods in clients with cardiac disease during pregnancy.

D. Supine: Supine positioning can compress the inferior vena cava and aorta, reducing venous return and cardiac output. This can lead to hypotension and decreased perfusion to both the mother and fetus, making it unsafe for pregnant clients with cardiac disease.

A. "What part of this assignment makes you upset?" B. "Let's discuss how this affects your performance improvement plan." C. "Why are you talking to me instead of the charge nurse?" D. "You are not the only one with a heavy assignment today."

Correct Answer is A

Explanation

A. "What part of this assignment makes you upset?": This response encourages open communication, allowing the staff nurse to express specific concerns. It demonstrates active listening, validation of feelings, and promotes problem-solving in a professional and supportive manner.

B. "Let's discuss how this affects your performance improvement plan.": This response shifts the focus to evaluation or discipline rather than addressing the immediate concern. It may create defensiveness and does not validate the nurse’s feelings or allow for discussion of the assignment issue.

C. "Why are you talking to me instead of the charge nurse?": This response is dismissive and may discourage the staff nurse from voicing concerns in the future. It does not address the fairness of the assignment or explore potential solutions.

D. "You are not the only one with a heavy assignment today.": Comparing workloads minimizes the nurse’s concerns and can be perceived as unsupportive. It does not facilitate problem-solving or acknowledge the staff nurse’s feelings about the assignment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning care for a client who has a left hip fracture and is in Buck's traction. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 32 weeks of gestation and has a history of cardiac disease. In which of the following positions should the nurse place the client to promote optimal cardiac output?

Correct Answer is B

Explanation

A nurse manager is confronted by a staff nurse who states that an assignment is unfair. Which of the following responses should the nurse manager make?

Correct Answer is A

Explanation

A nurse is providing dietary teaching to a client who had an exacerbation of COPD. Which of the following information should the nurse include in the teaching?

A nurse discovers information about a client on a colleague's social media page. Which of the following actions should the nurse take?

The nurse is caring for a client. Which of the following 4 orders or prescriptions should the nurse anticipate? Select the 4 orders or prescriptions that the nurse should anticipate.

A nurse is providing nutritional teaching to a client who is experiencing severe nausea due to gastroenteritis. Which of the following responses by the client indicates an understanding of the teaching?

A nurse in a mental health clinic is assessing a client who was recently diagnosed with anorexia nervosa. Which of the following findings should the nurse identify as an indication of laxative misuse?

A nurse is providing teaching to a client who is formula feeding their newborn. Which of the following information should the nurse include in the teaching to minimize their newborn's spit-up?

A nurse is caring for a client who reports difficulty sleeping and has a new diagnosis of sleep apnea. Which of the following statements by the client should the nurse expect?

A nurse is teaching a client about routine prenatal testing, which of the following statements should the nurse include in the teaching?