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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Extension cords placed under area rugs: Placing extension cords under rugs creates a fire hazard and increases the risk of electrical shock. It can also cause trips and falls if the cords shift or become damaged, making it an unsafe environmental practice.
B. Refrigerator temperature is 3.3° C (38° F): This temperature is within the recommended safe range for storing perishable food, helping prevent bacterial growth. It does not pose a safety hazard.
C. Covers placed on unused electrical outlets: Outlet covers prevent children from inserting objects into outlets, reducing the risk of electrical shock. This is considered a positive safety measure, not a hazard.
D. A lamp plugged directly into a wall outlet: Plugging a lamp directly into a wall outlet is standard and safe when the outlet is not overloaded. It does not present a hazard under normal use.
Correct Answer is A
Explanation
A. Assess for bladder distention: A full bladder can prevent the uterus from contracting effectively, leading to a boggy fundus and increased risk of postpartum hemorrhage. Assessing and addressing bladder distention is the priority because it directly impacts uterine tone and hemorrhage prevention.
B. Apply supplemental oxygen via nonrebreather mask: Oxygen may be necessary if the client shows signs of hypoxia or shock, but it does not address the primary cause of a boggy uterus. The priority is to correct the underlying issue affecting uterine contraction.
C. Administer intramuscular methylergonovine: Methylergonovine is used to promote uterine contraction, but pharmacologic intervention should follow initial assessment to identify reversible causes such as bladder distention. Administering medication without assessment could overlook a correctable mechanical issue.
D. Analyze coagulation studies: Coagulation studies are important if bleeding persists or coagulopathy is suspected, but they are not the immediate priority in a client with a boggy fundus shortly after birth. Immediate interventions to promote uterine contraction take precedence.
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