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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Green vegetables, whole wheat pasta, and poultry are not the best foods to include in the teaching plan when educating a client on increased calcium intake, as they are not rich sources of calcium. Green vegetables, such as kale, spinach, or broccoli, contain some calcium, but they also have oxalates, which can reduce the calcium absorption. Whole wheat pasta and poultry have very little calcium, and they are more sources of carbohydrates and protein, respectively.

Choice B reason: Low-fat milk, salmon with bones, and yogurt are the best foods to include in the teaching plan when educating a client on increased calcium intake, as they are high sources of calcium. Low-fat milk has about 300 mg of calcium per cup, salmon with bones has about 200 mg of calcium per 3 ounces, and yogurt has about 450 mg of calcium per cup. These foods also provide other nutrients, such as protein, vitamin D, and omega-3 fatty acids, which are beneficial for bone health.

Choice C reason: Fish, eggs, and potatoes are not the best foods to include in the teaching plan when educating a client on increased calcium intake, as they are not rich sources of calcium. Fish, such as tuna, cod, or halibut, have some calcium, but only if they are eaten with bones, which is not common. Eggs have about 25 mg of calcium per egg, which is very low. Potatoes have about 20 mg of calcium per medium potato, which is also very low.

Choice D reason: Poultry, broccoli, and yellow vegetables are not the best foods to include in the teaching plan when educating a client on increased calcium intake, as they are not rich sources of calcium. Poultry, such as chicken, turkey, or duck, have very little calcium, and they are more sources of protein and iron. Broccoli has about 40 mg of calcium per cup, which is low. Yellow vegetables, such as carrots, squash, or corn, have very little or no calcium, and they are more sources of vitamin A and fiber.

Choice E reason: Cheese, almonds, and tofu are not the best foods to include in the teaching plan when educating a client on increased calcium intake, as they are not suitable for everyone. Cheese has about 200 mg of calcium per ounce, but it is also high in fat, sodium, and calories, which may not be good for clients with high blood pressure, high cholesterol, or obesity. Almonds have about 75 mg of calcium per ounce, but they are also high in calories, and they may cause allergic reactions in some people. Tofu has about 250 mg of calcium per half cup, but it is also high in phytoestrogens, which may interfere with hormone levels in some people.

A. Grouped vesicles on the genitalia B. Hematoma on upper right arm C. Group of vesicles in linear patches along the spinal nerves D. Group of vesicles occurring on the lips and oral mucous membranes E. None of the above

Correct Answer is C

Explanation

Choice A reason: Grouped vesicles on the genitalia are not a typical presentation of shingles, but a sign of genital herpes, which is a sexually transmitted infection caused by a different type of herpes virus.

Choice B reason: Hematoma on upper right arm is not a common presentation of shingles, but a sign of bleeding or bruising under the skin, which may be caused by trauma, injury, or coagulation disorders.

Choice C reason: Group of vesicles in linear patches along the spinal nerves is a classic presentation of shingles, as it indicates the reactivation of the varicella-zoster virus, which causes chickenpox in childhood and remains dormant in the nerve cells. The virus can cause a painful rash that follows the distribution of the affected nerves, usually on one side of the body.

Choice D reason: Group of vesicles occurring on the lips and oral mucous membranes are not a characteristic presentation of shingles, but a sign of oral herpes, which is a common infection caused by a different type of herpes virus.

Choice E reason: None of the above is not a correct choice, as there is one option that matches the presentation of shingles

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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?

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