In caring for a client with Buck's traction, the practical nurse (PN) observes that the prescribed amount of weights are hanging freely and the traction rope is on the pulley. Which action should the PN implement next?
Document that the Buck's traction is being maintained.
Adjust the traction rope so it is free from the pulley.
Place the weights on blocks to increase their stability.
Contact the orthopedic technician to adjust the traction.
The Correct Answer is A
A. Document that the Buck's traction is being maintained: The weights are hanging freely and the rope is properly aligned on the pulley, indicating that Buck’s traction is functioning as prescribed. Accurate documentation confirms the traction setup is effective and the client’s treatment is being properly maintained.
B. Adjust the traction rope so it is free from the pulley: The rope should remain on the pulley to maintain continuous traction. Adjusting it unnecessarily could disrupt alignment, alter the amount of force applied, and compromise immobilization of the affected limb.
C. Place the weights on blocks to increase their stability: Weights should never rest on any surface, as doing so removes the continuous pulling force required for effective traction. Interfering with the weights’ free-hanging position can reduce traction effectiveness and cause complications.
D. Contact the orthopedic technician to adjust the traction: Since the traction setup is correct, there is no need to call for adjustment. The PN should continue to monitor the system for alignment, tension, and client comfort, documenting findings as part of routine care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Ensure that the client's arm remains elevated after the blood pressure is recorded: Elevation of the operative arm is important for comfort and edema prevention, but it does not address the risk of lymphedema caused by applying a blood pressure cuff to the surgical side.
B. Review the client's blood pressure as soon as the UAP records the measurement: Reviewing the reading does not prevent potential harm to the operative arm. The priority is preventing injury or complications before the measurement is taken.
C. Instruct the UAP to measure the client's blood pressure on the non-operative side: Blood pressure should never be measured on the side of a mastectomy because cuff pressure can increase the risk of lymphedema and impair healing. Directing the UAP to use the non-operative arm protects the client and follows best practice guidelines.
D. Advise the UAP to use a manual blood pressure cuff for a more accurate reading: Accuracy is not the issue in this situation; the priority is preventing trauma to the operative arm. Using a manual cuff on the surgical side still poses a risk.
Correct Answer is ["600"]
Explanation
Convert all fluid intake from ounces (oz) to milliliters (mL) using the standard conversion factor of 1 oz = 30 mL.
0800: 4 oz apple juice × 30 mL/oz = 120 mL
1200: 8 oz milk × 30 mL/oz = 240 mL
1200: 4 oz broth × 30 mL/oz = 120 mL
1500: 4 oz tea × 30 mL/oz = 120 mL
Sum all the converted volumes to get the total intake in mL.
Total Intake (mL) = 120 mL (juice) + 240 mL (milk) + 120 mL (broth) + 120 mL (tea)
= 600 mL.
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