The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?

Weak pedal pulses.

Complaints of leg discomfort.

Toes are warm and demonstrate a brisk capillary refill.

Drainage at the pin sites.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Weak pedal pulses indicate vascular compromise, which is a complication of Buck’s traction. This can be caused by pressure on the tissues of the leg.

Choice B rationale

Complaints of leg discomfort are expected due to the traction and do not indicate a complication.

Choice C rationale

Toes that are warm and demonstrate brisk capillary refill are normal findings and do not indicate a complication.

Choice D rationale

Drainage at the pin sites is more relevant to skeletal traction, not Buck’s traction.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A rationale

Providing diversionary activities for the client can help distract them and reduce the likelihood of them pulling on their NG tube. Diversionary activities can include engaging the client in conversation, providing them with puzzles or games, or allowing them to watch television or listen to music. These activities can help occupy the client’s time and attention, reducing the need for restraints.

Choice B rationale

Assisting the client with toileting at frequent intervals can address any discomfort or need that may be causing the client to pull on their NG tube. Ensuring that the client is comfortable and their needs are met can reduce agitation and the likelihood of them pulling on the tube.

Choice C rationale

Involving the family in the client’s care can provide additional support and reassurance to the client. Family members can help calm the client and provide a familiar presence, which can reduce anxiety and the need for restraints.

Choice E rationale

Using an electronic bed alarm device can alert the nursing staff if the client attempts to get out of bed or pull on their NG tube. This allows for timely intervention without the need for physical restraints.

A. Pancreatic pseudocyst. B. Electrolyte imbalance. C. Internal bleeding. D. Pleural effusion.

Correct Answer is C

Explanation

Choice A rationale

Pancreatic pseudocyst is a complication of acute pancreatitis, but it is not directly associated with Cullen’s sign. Cullen’s sign indicates periumbilical ecchymosis, which is a sign of internal bleeding.

Choice B rationale

Electrolyte imbalance can occur in acute pancreatitis, but it is not indicated by Cullen’s sign. Cullen’s sign specifically points to internal bleeding.

Choice C rationale

Internal bleeding is the correct answer. Cullen’s sign is a bluish discoloration around the umbilicus, indicating bleeding within the abdomen. This can occur in severe cases of acute pancreatitis due to hemorrhage.

Choice D rationale

Pleural effusion can be a complication of acute pancreatitis, but it is not indicated by Cullen’s sign. Cullen’s sign is specific to internal bleeding.

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The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

Upon assessment, Cullen’s sign is noted. What complication of acute pancreatitis would the nurse suspect that the client might have?

Correct Answer is C

Explanation

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