Nokea
Which nursing action is appropriate while the client is being transported?
- A. The nurse leaves the traction as is.
- B. The nurse removes the weights during the transport.
- C. The nurse rests the weights on the end of the bed.
- D. The nurse takes the client's leg out of the traction.
Correct Answer: B
Rationale: Removing the weights during transport prevents unintended movement or injury while maintaining the leg's position. Leaving traction as is or resting weights risks disrupting alignment, and removing the leg negates traction benefits.
You may also like to solve these questions
Which is the best method to assess circulation in the casted extremity?
- A. Ask the client to wiggle the fingers.
- B. Feel the cast to determine if it is unusually hot or cold.
- C. Depress the client's nail beds, and document the client's knee on the center to return.
- D. See if there is enough room to insert a finger between the cast and the extremity.
Correct Answer: C
Rationale: Depressing the nail beds to assess capillary refill (color return within 2-3 seconds) is the most reliable method to evaluate circulation in a casted extremity, indicating adequate blood flow. Wiggling fingers assesses motor function, not circulation directly, and the other options are less specific.
The client with a long arm cast is complaining of unrelenting severe pain and feeling as if the fingers are asleep. Which complication should the nurse suspect the client is experiencing?
- A. Fat embolism.
- B. Compartment syndrome.
- C. Pressure ulcer under the cast.
- D. Surgical incision infection.
Correct Answer: B
Rationale: Severe pain and numbness in a casted arm suggest compartment syndrome, a medical emergency. Fat embolism, pressure ulcers, and infections present differently.
The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement?
- A. Adjust the patient-controlled analgesia (PCA) machine for a lower dose.
- B. Ensure the weights of the Buck's traction are off the floor and hang freely.
- C. Raise the head of the bed to 45 degrees and the foot to 15 degrees.
- D. Turn the client on the affected leg using pillows to support the other leg.
Correct Answer: B
Rationale: Proper Buck’s traction alignment (weights off floor) reduces pain from misalignment. Adjusting PCA, bed positioning, or turning may worsen pain or are inappropriate.
The client is postoperative open reduction and internal fixation (ORIF) of a fractured femoral neck. Which long-term goal should the nurse identify for the client?
- A. The client will maintain vital signs within normal limits.
- B. The client will have a decrease in muscle spasms in the affected leg.
- C. The client will have no signs or symptoms of infection.
- D. The client will be able to ambulate down to the nurse’s station.
Correct Answer: D
Rationale: Ambulation to the nurse’s station is a long-term goal post-ORIF, indicating restored mobility. Vital signs, spasms, and infection are short-term or secondary.
The 62-year-old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below-the-knee amputation. Which nursing intervention should the nurse implement?
- A. Assess the client's nutritional status.
- B. Refer the client to an occupational therapist.
- C. Determine if the client is allergic to IVP dye.
- D. Start a 22-gauge Angiocath in the right arm.
Correct Answer: A
Rationale: Nutritional status assessment ensures adequate healing post-amputation, critical in diabetes. OT referral is postoperative, IVP dye is irrelevant, and a 22-gauge IV is too small for surgery.