On entering the room of a child in Buck’s traction, the nurse makes all of the following observations. Which observation requires a nursing intervention?
Child’s heels are placed firmly against the foot of the bed.
Head of bed is elevated 20 degrees.
Weights are hanging freely.
Ropes are on pulleys.
The Correct Answer is A
Choice A reason: Heels against the bed in Buck’s traction cause pressure, risking skin breakdown or ulcers, especially in children with sensitive skin. This requires intervention (e.g., repositioning or padding) to prevent tissue damage and ensure traction maintains fracture alignment without complications.
Choice B reason: Elevating the head of the bed 20 degrees is acceptable in Buck’s traction, as it promotes comfort and does not disrupt the traction’s alignment or force. It is not a concern requiring intervention unless it affects traction mechanics.
Choice C reason: Freely hanging weights are correct in Buck’s traction, ensuring consistent force to align the fracture. This is a desired observation, as obstructed weights would disrupt traction efficacy, and no intervention is needed for this finding.
Choice D reason: Ropes on pulleys are essential for Buck’s traction to function, allowing smooth force transmission to align the fracture. This is a correct setup, requiring no intervention, as it ensures the traction system operates effectively without mechanical issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Bisphosphonates are generally safe for clients with diabetes and normal renal function (serum creatinine 0.8 mg/dL is within normal range, indicating adequate kidney function). These drugs inhibit osteoclast activity, reducing bone resorption, and are not contraindicated in diabetes unless renal impairment is present, which is not the case here.
Choice B reason: Vertebral compression fractures are a common complication of osteoporosis. Bisphosphonates are often prescribed to strengthen bones and prevent further fractures by inhibiting bone resorption. Recent fractures do not contraindicate their use; in fact, they are indicated to improve bone density and reduce future fracture risk.
Choice C reason: Calcium channel blockers, used for hypertension, do not interact significantly with bisphosphonates. These drugs work on different systems—bisphosphonates on bone metabolism and calcium channel blockers on vascular smooth muscle. There is no evidence suggesting this combination poses a risk, making bisphosphonates appropriate for this client.
Choice D reason: Bisphosphonates, especially oral ones, require patients to sit upright for 30–60 minutes post-dose to prevent esophageal irritation and ensure proper absorption. A client with a spinal cord injury unable to tolerate sitting up cannot comply with this requirement, increasing the risk of esophageal damage, making bisphosphonates a poor choice.
Correct Answer is B
Explanation
Choice A reason: Warm baths may help with MS-related spasticity but are not the priority teaching for cyclophosphamide and methylprednisolone. These drugs focus on immunosuppression and inflammation control, and baths do not address their side effects or infection risks.
Choice B reason: Cyclophosphamide and methylprednisolone are immunosuppressants, reducing white blood cell counts and increasing infection risk. Avoiding crowds and sick individuals minimizes exposure to pathogens, critical for preventing infections like pneumonia in MS patients on these medications.
Choice C reason: Using a walker supports mobility in MS without necessarily weakening gait. It aids safety during exacerbations, and discouraging its use is inappropriate, as it does not address the immunosuppressive risks of the prescribed medications.
Choice D reason: Taking cyclophosphamide and methylprednisolone only when symptoms occur is incorrect, as these drugs require consistent dosing for immunosuppression and inflammation control. Symptom-based dosing reduces efficacy and increases relapse risk in MS management.
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