A nurse is collecting data from a client who is in Buck's traction. Which of the following findings indicates the traction is functioning correctly?

The weights apply a pulling force continuously.

The boot allows active leg movement.

The footplate rests against the foot of the bed.

The weights are just touching the floor.

Answer and Explanation

The Correct Answer is A

Rationale:

A. The weights apply a pulling force continuously: Buck’s traction is a form of skin traction used to immobilize fractures and reduce muscle spasms. The weights must hang freely and provide a constant pulling force to maintain alignment and promote healing.

B. The boot allows active leg movement: In Buck’s traction, the affected leg should be immobilized. Active movement would interfere with the consistent traction force and compromise the effectiveness of the treatment.

C. The footplate rests against the foot of the bed: The client’s foot should not press against the bedframe or footplate, as this can counteract the traction force and cause improper alignment. There should be adequate space for traction to be effective.

D. The weights are just touching the floor: Weights should hang freely and never touch the floor. If they rest on the floor, the traction force is lost, defeating the purpose of the setup and potentially leading to complications.

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Correct Answer is ["A","C"]

Explanation

Rationale:

• Naloxone: The client received fentanyl and is now showing signs of opioid-induced respiratory depression. Respiratory rate has decreased to 10/min and oxygen saturation to 87%. Naloxone will reverse the opioid’s effects and restore adequate respiratory effort.

• An additional dose of propofol: The client’s level of sedation is already too deep, as shown by low respiratory rate and blood pressure. Additional propofol would worsen central nervous system depression. It may cause complete apnea or cardiac compromise in this situation.

• Oxygen 10 L/min via face mask: The current oxygen flow via nasal cannula is insufficient given the client's low oxygen saturation. A face mask delivers higher oxygen concentration and flow. This is critical to correct hypoxia until the cause is reversed.

• Acetaminophen: There is no fever or current complaint of pain requiring antipyretics or analgesics. Administering acetaminophen now would not address the acute respiratory issue. It would delay more urgent and appropriate interventions.

• An additional dose of fentanyl: Administering more opioid would increase the risk of further respiratory depression. The client is already showing hypoventilation and declining oxygenation. More fentanyl would worsen sedation and endanger airway and breathing.

• Propranolol: The client is already hypotensive with a BP of 80/51 mm Hg and a heart rate of 68/min. Giving a beta blocker could severely depress cardiac output. This would increase the risk of organ hypoperfusion and cardiac arrest.

A. "We will keep the number for poison control stored in our phones. B. "We will make sure our hot water heater is set to 54° C (129° F) C. "We will make sure to turn pot handles towards the front of the stove." D. "We will store medications on a high surface that our child can't reach"

Correct Answer is A

Explanation

Rationale:

A. "We will keep the number for poison control stored in our phones.": Having the poison control number readily accessible is a key component of home safety for toddlers, who are at high risk for accidental ingestion. Prompt access supports rapid emergency response and guidance.

B. "We will make sure our hot water heater is set to 54° C (129° F)": This temperature setting is too high and increases the risk of scald burns. Water heaters should be set at or below 49° C (120° F) to reduce the chance of accidental burns during bathing or handwashing.

C. "We will make sure to turn pot handles towards the front of the stove.": Turning pot handles to the front makes them easier for a toddler to grab, increasing burn and injury risk. Handles should always be turned toward the back or center of the stove to keep them out of reach.

D. "We will store medications on a high surface that our child can't reach": High surfaces are not secure enough, as toddlers may climb. Medications should be stored in locked cabinets to ensure they are completely inaccessible to curious children.

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A nurse is collecting data from a client who is in Buck's traction. Which of the following findings indicates the traction is functioning correctly?

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