A nurse is caring for a client who has a fractured hip and is in Buck's traction prior to surgical repair. What should the nurse include in the plan of care?
Perform a neurovascular assessment of the extremity daily
Assess the client's skin condition under the boot weekly
Increase the traction if the client complains of increased pain
Ensure that the traction weights do not touch the floor
The Correct Answer is D
Choice A reason: Performing a neurovascular assessment of the extremity daily is not enough. The nurse should perform this assessment every 2 to 4 hours to monitor for signs of impaired circulation or nerve function.
Choice B reason: Assessing the client's skin condition under the boot weekly is not enough. The nurse should assess the skin under the boot at least once a day to prevent skin breakdown and infection.
Choice C reason: Increasing the traction if the client complains of increased pain is not appropriate. The nurse should not adjust the traction without a provider's order. Increasing the traction could cause more damage to the fracture site or the surrounding tissues.
Choice D reason: Ensuring that the traction weights do not touch the floor is the correct action. The nurse should make sure that the weights are hanging freely and not resting on anything. This ensures that the traction is applied continuously and evenly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Staphylococcus aureus is the most common pathogen to cause osteomyelitis, as it is a gram-positive bacterium that can invade the bone through the bloodstream, a wound, or a surgical site. It can cause acute or chronic inflammation and infection of the bone and bone marrow.
Choice B reason: Escherichia coli is not the most common pathogen to cause osteomyelitis, as it is a gram-negative bacterium that is usually found in the gastrointestinal tract. It can cause urinary tract infections, diarrhea, or sepsis, but it is not a frequent cause of bone infections.
Choice C reason: Proteus mirabilis is not the most common pathogen to cause osteomyelitis, as it is a gram-negative bacterium that is usually found in the urinary tract. It can cause urinary tract infections, kidney stones, or septicemia, but it is not a common cause of bone infections.
Choice D reason: Pseudomonas aeruginosa is not the most common pathogen to cause osteomyelitis, as it is a gram-negative bacterium that is usually found in moist environments. It can cause skin infections, pneumonia, or septic shock, but it is not a frequent cause of bone infections.
Choice E reason: None of the above is not a correct choice, as there is one option that matches the most common pathogen to cause osteomyelitis.
Correct Answer is B
Explanation
Choice A reason: Institute of Medicine (IOM) research is not a method for developing procedures, but an organization that conducts health-related studies and provides recommendations for improving health care quality and safety.
Choice B reason: Evidence-based practice is the correct method for developing procedures. It is the process of integrating the best available research evidence with clinical expertise and patient preferences to make decisions about health care.
Choice C reason: Knowledge, skills, and attitude are not a method for developing procedures, but the components of competency that nurses need to provide safe and effective care.
Choice D reason: Core measures are not a method for developing procedures, but a set of standardized performance indicators that evaluate the quality of care for specific conditions or procedures.
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