A nurse is planning care for a client who has a left hip fracture and is in Buck's traction. Which of the following interventions should the nurse include in the plan of care?

Inspect the skin under the boot every 8 hr.

Assess the client's peripheral circulation every 12 hr.

Ensure the weights are resting on the floor.

Remove the traction to allow the client to use the bathroom.

Answer and Explanation

The Correct Answer is A

A. Inspect the skin under the boot every 8 hr: Frequent skin assessment is critical for clients in Buck's traction because the traction boot or straps can cause pressure injuries, skin breakdown, or irritation. Checking the skin every 8 hours allows early detection of redness, sores, or areas of compromised circulation and prevents complications associated with prolonged immobility and pressure.

B. Assess the client's peripheral circulation every 12 hr: Peripheral circulation should be assessed more frequently than every 12 hours, typically every 1–2 hours initially, to detect early signs of neurovascular compromise such as cyanosis, pallor, coolness, or numbness. Waiting 12 hours could delay identification of circulation issues that may lead to tissue damage or compartment syndrome.

C. Ensure the weights are resting on the floor: Traction weights must hang freely to maintain proper alignment and effective traction. Allowing the weights to rest on the floor disrupts the pulling force, reducing traction effectiveness, increasing pain, and potentially worsening fracture displacement.

D. Remove the traction to allow the client to use the bathroom: Buck's traction should not be removed for routine activities such as toileting because interrupting traction can cause misalignment, increased pain, and delayed healing. Alternative methods, such as a bedside commode or urinal, should be used while maintaining traction integrity.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Tachycardia: Amphetamines are central nervous system stimulants that increase sympathetic nervous system activity. Tachycardia is a common manifestation of acute toxicity, along with hypertension, hyperthermia, and agitation. Monitoring cardiovascular status is essential to prevent complications.

B. Headache: While headaches can occur with amphetamine use, they are not a primary or consistent finding in acute toxicity. More prominent signs are cardiovascular and neurological stimulation rather than mild symptoms like headache.

C. Increased appetite: Amphetamines typically suppress appetite rather than increase it. Clients experiencing acute toxicity are more likely to have decreased hunger due to stimulant effects on the hypothalamus.

D. Pupil constriction: Amphetamines usually cause mydriasis (pupil dilation) due to sympathetic stimulation. Pupil constriction is more characteristic of opioid toxicity rather than amphetamine toxicity.

A. Administer a dose of fluoxetine to the client. B. Avoid making eye contact with the client. C. Request the client to lie down in a quiet room. D. Encourage the client to listen to music.

Correct Answer is D

Explanation

A. Administer a dose of fluoxetine to the client: Fluoxetine is an antidepressant and is not indicated for acute psychotic symptoms such as auditory hallucinations in schizophrenia. Antipsychotic medications, not SSRIs, are the standard treatment for managing hallucinations.

B. Avoid making eye contact with the client: Avoiding eye contact can be perceived as disengagement or disinterest, which may increase the client’s anxiety or mistrust. Therapeutic communication with appropriate eye contact helps establish rapport and conveys presence and support.

C. Request the client to lie down in a quiet room: Forcing the client to lie down may increase distress or feelings of loss of control. While a quiet environment can reduce stimuli, the intervention should be voluntary and focused on coping strategies rather than directives.

D. Encourage the client to listen to music: Listening to music can help distract the client from hallucinations and provide a coping mechanism to reduce distress. This intervention supports safety, comfort, and engagement without confrontation, aligning with therapeutic approaches for managing auditory hallucinations.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning care for a client who has a left hip fracture and is in Buck's traction. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing acute amphetamine toxicity. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who has schizophrenia and is hearing voices. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who gave birth 4 hr ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving an epidural for labor pain. Which of the following actions should the nurse take?

A nurse is assessing a client 3 days following a hysterectomy. Which of the following findings should the nurse identify as an indication the client is developing a complication?

The nurse continues to care for the client. A nurse on the inpatient mental health unit is planning care for the client. For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client.

A nurse is documenting assessment findings for a client. Which of the following is an example of subjective data?

A nurse in an outpatient clinic is assessing a client who is pregnant for unsafe behaviors during pregnancy. Which of the following findings indicates a need for further evaluation?

A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is providing nutritional teaching to a client who is experiencing severe nausea due to gastroenteritis. Which of the following responses by the client indicates an understanding of the teaching?