A nurse is participating in an interprofessional team meeting for a client. Which of the following information about the client should the nurse Include?

The client has state-sponsored health insurance.

The client's vital signs are checked every 8 hr.

The client's next dressing change is scheduled in 4 hr.

The client has developed difficulty ambulating.

Answer and Explanation

The Correct Answer is D

Interprofessional team meetings focus on sharing relevant clinical changes that affect a client’s overall function, safety, and plan of care. Information provided should support coordinated decision-making among healthcare professionals such as physicians, nurses, physical therapists, and occupational therapists. Priority communication includes changes in the client’s condition that may require modification of treatment goals or additional interventions. Functional decline is especially important because it directly impacts mobility, safety, and discharge planning.

Rationale:
A. The client having state-sponsored health insurance is administrative information that does not influence immediate clinical decision-making or care planning. While it may be relevant for discharge planning or billing purposes, it does not affect interprofessional treatment strategies. Therefore, it is not essential for the team meeting focused on clinical care.

B. Vital signs being checked every 8 hours is a routine nursing task and does not represent a change in the client’s condition. It reflects standard monitoring rather than a clinical issue requiring interprofessional input. Such information is typically documented in nursing records rather than discussed in team meetings.

C. The next dressing change scheduled in 4 hours is a task-specific nursing detail rather than a multidisciplinary concern. Although wound care is important, timing of dressing changes does not typically require input from multiple disciplines unless complications arise. Therefore, it is not a priority for interprofessional discussion.

D. Development of difficulty ambulating is a significant functional change that requires interprofessional collaboration. It may indicate neurological decline, musculoskeletal impairment, medication effects, or deconditioning. In a condition such as Impaired physical mobility, this finding would prompt involvement of physical therapy, reassessment of safety risks, and possible modification of the care plan to prevent falls and promote rehabilitation.

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Correct Answer is D

Explanation

Buck’s traction is a type of skin traction used to immobilize and align fractures of the lower extremity by applying a steady pulling force to maintain bone alignment and reduce muscle spasm. Proper functioning of the system is essential to prevent complications such as neurovascular compromise, skin breakdown, and ineffective traction. Nursing care focuses on maintaining continuous, uninterrupted traction and monitoring circulation, sensation, and skin integrity in the affected limb. Proper setup ensures therapeutic effectiveness and patient safety in the management of lower extremity fractures.

Rationale:
A. Monitoring capillary refill once per day is insufficient because neurovascular assessment must be performed more frequently in clients with traction. Reduced blood flow can develop rapidly due to pressure or improper alignment. Capillary refill, pulses, sensation, and temperature should be assessed at regular intervals to detect early complications.

B. Maintaining elevation of the head of the bed is not directly related to Buck’s traction care. While slight elevation may be used for comfort or respiratory support, it does not ensure proper traction function. The primary focus is maintaining alignment and ensuring uninterrupted traction force on the affected extremity.

C. Checking the client’s skin twice daily is appropriate for skin integrity monitoring, but it is not the priority intervention compared to ensuring correct traction mechanics. Skin breakdown prevention is important, but ineffective traction due to displaced weights poses a more immediate risk to bone alignment and neurovascular status.

D. Ensuring the weights are hanging freely is essential because uninterrupted traction force is required for proper alignment of the fractured limb in Buck’s traction. Weights must never rest on the bed or floor, as this disrupts the continuous pull, leading to loss of alignment and reduced therapeutic effectiveness. Maintaining free-hanging weights ensures consistent traction and prevents complications such as muscle spasm and malalignment.

A. Follow facility protocol when performing a procedure on the client. B. Administer pain medication on a routine schedule. C. Keep an agreement made with the client to administer an antiemetic medication. D. Include the client's input when setting treatment goals.

Correct Answer is D

Explanation

Autonomy in healthcare refers to a client’s right to make informed decisions about their own care, including treatment preferences, goals, and end-of-life choices. In clients with terminal illness, respecting autonomy is especially important because care often shifts toward comfort, dignity, and individualized priorities. Nurses support autonomy by involving clients in decision-making, providing clear information, and honoring expressed wishes. This approach ensures care aligns with the client’s values rather than being solely provider-directed.

Rationale:
A. Following facility protocol when performing a procedure ensures safety and standardization of care, but it does not directly promote client autonomy. While protocols are important for consistency and risk reduction, they do not involve the client in decision-making or respect personal preferences.

B. Administering pain medication on a routine schedule promotes comfort and symptom control but is more related to beneficence than autonomy. It does not necessarily reflect the client’s participation in decisions about their care plan or treatment goals.

C. Keeping an agreement made with the client to administer an antiemetic medication demonstrates trust and reliability, but it primarily reflects fidelity rather than autonomy. While honoring agreements is important, it does not specifically involve the client in decision-making processes.

D. Including the client’s input when setting treatment goals directly supports autonomy by involving them in decisions about their care. In conditions such as Terminal cancer, this ensures care aligns with the client’s values, preferences, and desired quality of life. This shared decision-making is the clearest example of respecting and promoting autonomy.

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A nurse is participating in an interprofessional team meeting for a client. Which of the following information about the client should the nurse Include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in caring for a client who is in Buck's traction. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assisting in the care of a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?

Correct Answer is D

Explanation

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