Unlicensed assistive personnel (UAP) reports a client diagnosed with a fractured femur has "fatty globules" floating in the urinal. Which intervention should the nurse implement first?

Obtain an arterial blood gas and order a portable chest x-ray.

Instruct the UAP to keep the client on strict bed rest.

Assess the client for dyspnea and altered mental status.

Contact the healthcare provider for a ventilation and perfusion scan.

Answer and Explanation

The Correct Answer is C

A. Obtaining an arterial blood gas and ordering a chest x-ray may be necessary to evaluate the client further, but the nurse must first assess the client to determine the presence of clinical signs of fat embolism syndrome (FES), such as respiratory distress or neurological changes.

B. Keeping the client on strict bed rest may help reduce the risk of further complications, but it is not the first priority. Immediate assessment of the client’s condition is necessary to identify signs of fat embolism syndrome.

C. Assessing the client for dyspnea and altered mental status is the first priority because these symptoms are early indicators of fat embolism syndrome. Early recognition and intervention are critical in preventing further complications.

D. Contacting the healthcare provider for a ventilation and perfusion scan may be appropriate after assessing the client, but it is not the first action. Immediate assessment is essential to determine the urgency of the situation.

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Correct Answer is D

Explanation

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.

A. Buck's extension traction will reduce the fracture. B. Buck's extension traction will maintain alignment of the pins. C. Buck's extension traction will relieve muscle spasms. D. Buck's extension traction will allow supported movement of the extremity.

Correct Answer is C

Explanation

A. Buck's extension traction is not used to reduce fractures but to provide comfort, maintain alignment, and reduce muscle spasms in the affected area. Reduction of the fracture typically occurs through surgical intervention.

B. Buck's extension traction is not used to maintain the alignment of pins, as there are no pins involved in this type of traction. It is designed to relieve muscle spasms and provide comfort to the affected limb.

C. Buck's extension traction is primarily used to relieve muscle spasms and provide a steady pull on the affected limb to maintain alignment and reduce pain. This is particularly important in hip fractures to prevent further injury and discomfort.

D. Buck's extension traction does not allow for supported movement of the extremity; instead, it helps to immobilize the limb and reduce muscle spasms.

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Unlicensed assistive personnel (UAP) reports a client diagnosed with a fractured femur has "fatty globules" floating in the urinal. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching?

Correct Answer is C

Explanation

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