A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg.
Which of the following interventions should the nurse delegate to an assistive personnel?
Observe the position of the suspended weight
Check the client’s pedal pulse on the right leg
Ask the client to describe her pain
Remind the client to use the incentive spirometer
The Correct Answer is A
The correct answer is choice A. Observe the position of the suspended weight.
This is an intervention that the nurse can delegate to an assistive personnel because it does not require clinical judgment or assessment skills.
The nurse should instruct the assistive personnel to report any changes in the position of the weight or the traction system to the nurse immediately.
Choice B is wrong because checking the client’s pedal pulse on the right leg requires assessment skills and clinical judgment that are beyond the scope of practice of an assistive personnel.
The nurse should perform this intervention to monitor the client’s circulation and nerve function in the affected limb.
Choice C is wrong because asking the client to describe her pain requires communication and assessment skills that are beyond the scope of practice of an assistive personnel.
The nurse should perform this intervention to evaluate the client’s pain level and response to analgesics.
Choice D is wrong because reminding the client to use the incentive spirometer requires teaching and evaluation skills that are beyond the scope of practice of an assistive personnel.
The nurse should perform this intervention to promote effective gas exchange and prevent respiratory complications in the client who is immobile.
Buck’s traction is a type of skin traction that is applied by strapping the client’s affected lower limb and attaching weights. The purpose of traction is to restore and maintain straight alignment and length of bones following fractures, to limit movement and reduce pain, spasms and swelling. Normal ranges for skin traction are 2.3 to 4.5 kg for adults and 0.9 to 2.3 kg for children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Administer a cathartic suppository 30 min prior to scheduled defecation times. This is because a cathartic suppository stimulates the nerve endings in the rectum, causing a contraction of the bowel and facilitating defecation. This is especially helpful for clients who have an upper motor neuron or reflexic bowel, which means they have lost the ability to feel when the rectum is full and have a tight anal sphincter muscle. A
bowel program is a way of controlling or moving the bowels after a spinal cord injury, which may affect normal bowel function depending on the spinal level involved. A bowel program aims to achieve regular bowel movements, prevent constipation or impaction, and avoid accidents.
Choice A is wrong because encouraging a maximum fluid intake of 1,500 mL per day is not enough to prevent constipation and promote bowel health. A fluid intake of at least 2,000 mL per day is recommended for most adults.
Choice B is wrong because increasing the amount of refined grains in the client’s diet can worsen constipation and reduce stool bulk.
Refined grains are low in fiber, which is essential for normal bowel function. A high-fiber diet of at least 20 to 35 grams per day is advised for clients with spinal cord injury.
Choice C is wrong because providing the client with a cold drink prior to defecation can have the opposite effect of stimulating the bowel.
Cold drinks can slow down the digestive process and reduce peristalsis, which is the movement of food through the intestines. Warm or hot drinks can help stimulate the bowel and increase peristalsis.
Correct Answer is A
Explanation
a. Apply intermittent pressure 2.5 cm (1 inch) below the percutaneous skin site.
- Rationale:Applying intermittent pressure slightly below the puncture site can help control bleeding without dislodging the introducer sheath,which is still in place at this early stage.
b. Apply direct pressure to the puncture site.
- Rationale:NOT the best choice.Applying direct pressure to the puncture site itself could dislodge the introducer sheath and worsen bleeding.
c. Elevate the affected extremity above the level of the heart.
- Rationale:NOT the best choice.While elevating the extremity may help reduce swelling,it is not the most effective intervention for controlling bleeding at the puncture site.
d. Leave the dressing undisturbed and notify the physician immediately.
- Rationale:NOT the best choice.While notifying the physician is important,delaying intervention to control bleeding could worsen the situation.Early intervention is crucial.
Therefore, the correct answer is a. Apply intermittent pressure 2.5 cm (1 inch) below the percutaneous skin site. This approach helps control bleeding while minimizing the risk of dislodging the introducer sheath.
Remember, in such situations, prioritizing prompt intervention and preventing further blood loss is crucial while waiting for medical assistance.
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