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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?
- A. Weak pedal pulses.
- B. Complaints of leg discomfort.
- C. Toes are warm and demonstrate a brisk capillary refill.
- D. Drainage at the pin sites.
Correct Answer: A
Rationale: The correct answer is A: Weak pedal pulses. Buck's traction is used for immobilization and alignment of fractures, particularly femoral fractures. Weak pedal pulses indicate impaired circulation, which could lead to complications like compartment syndrome or deep vein thrombosis. Monitoring pulses is crucial in assessing the circulation to the affected limb. Choice B (Complaints of leg discomfort) is common and expected with traction but doesn't indicate a complication. Choice C (Toes are warm and demonstrate a brisk capillary refill) indicates good circulation. Choice D (Drainage at the pin sites) may indicate infection but is not a specific complication related to traction.
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The nurse is assigned to care for a client who is 2 days postoperative after an above-the-knee amputation of the right leg. The nurse plans to implement which measure to prevent hip contractures?
- A. Maintain the client in a supine position.
- B. Maintain a high-Fowler’s position when the client is in bed.
- C. Elevate the stump on a pillow.
- D. Position the client on the abdomen for 20 to 30 minutes twice a day.
Correct Answer: D
Rationale: Correct Answer: D. Position the client on the abdomen for 20 to 30 minutes twice a day.
Rationale: Positioning the client on the abdomen helps prevent hip contractures by stretching the hip flexors and maintaining hip extension. This position also helps to prevent hip adduction contractures, which can occur due to prolonged positioning on the back. By alternating positions, the client's hip joint is kept in a more functional and extended position, reducing the risk of contractures.
Summary of other choices:
A: Maintaining the client in a supine position does not actively prevent hip contractures and may even contribute to hip flexion contractures.
B: Maintaining a high-Fowler's position when the client is in bed does not address hip extension and may lead to hip flexion contractures.
C: Elevating the stump on a pillow is important for stump care but does not specifically target prevention of hip contractures.
A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skin traction. The nurse may remove the weights from the traction device if which of the following occurs?
- A. The client develops a life-threatening situation.
- B. The client has to be repositioned in the bed.
- C. The client complains of pain.
- D. The client needs to have an x-ray of the femur performed.
Correct Answer: A
Rationale: The correct answer is A: The client develops a life-threatening situation. In this scenario, the nurse can remove the weights from the traction device to address the life-threatening situation promptly. Removing the weights in such a situation takes precedence over other concerns like repositioning, pain complaints, or even the need for an x-ray. Life-threatening situations must always be prioritized in patient care to ensure their safety and well-being. It is crucial for the nurse to act swiftly and appropriately in such emergencies to provide the necessary care and support to the client.
A client is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA) to treat coronary artery disease. What information about the balloon-tipped catheter would the nurse plan to include when providing client education concerning the procedure?
- A. A mesh-like device within the catheter will be inflated causing it to spring open.
- B. The catheter will be positioned in a coronary artery to take pressure measurements in the vessel.
- C. The catheter will be used to compress the plaque against the coronary blood vessel wall.
- D. The catheter will cut away the plaque from the coronary vessel wall using an embedded blade.
Correct Answer: C
Rationale: Correct Answer: C - The catheter will be used to compress the plaque against the coronary blood vessel wall.
Rationale: During a PTCA procedure, a balloon-tipped catheter is used to compress the plaque against the vessel wall, widening the artery lumen and improving blood flow. This process does not involve cutting away the plaque or taking pressure measurements. Option A is incorrect as the catheter does not spring open but rather compresses the plaque. Option B is incorrect as the catheter is not used for pressure measurements. Option D is incorrect as there is no embedded blade to cut away the plaque.
A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?
- A. Serosanguineous drainage.
- B. Mild erythema.
- C. Warmth.
- D. Fever.
Correct Answer: D
Rationale: The correct answer is D: Fever. Infection at the pin sites in skeletal traction can lead to systemic signs such as fever. Fever is a common indicator of infection as the body responds to pathogens by increasing its temperature. Serosanguineous drainage, mild erythema, and warmth can be normal findings in the early stages of healing or due to inflammation, but fever indicates a more serious underlying issue like infection. Therefore, the nurse should prioritize monitoring for fever to promptly identify and address any potential infection.
A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?
- A. The ropes are in the center of the wheel grooves.
- B. The ropes are securely attached to the pins.
- C. The weights are equal on each side.
- D. The weights rest against the foot of the bed.
Correct Answer: D
Rationale: The correct answer is D because the weights in skeletal traction should not rest against the foot of the bed to ensure proper traction force. The weights need to hang freely to provide continuous traction on the affected body part. Placing the weights against the foot of the bed could lead to uneven or inadequate traction force, affecting the treatment effectiveness and potentially causing harm to the client.
Choice A is incorrect because the ropes should be in the center of the wheel grooves to maintain proper alignment and prevent slipping. Choice B is incorrect because the ropes should be securely attached to the pins to ensure stability and prevent accidental detachment. Choice C is incorrect because the weights do not need to be equal on each side; the amount of weight applied is determined by the healthcare provider based on the specific treatment plan.