The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?

Weak pedal pulses.

Complaints of leg discomfort.

Toes are warm and demonstrate a brisk capillary refill.

Drainage at the pin sites.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Weak pedal pulses indicate vascular compromise, which is a complication of Buck’s traction. This can be caused by pressure on the tissues of the leg.

Choice B rationale

Complaints of leg discomfort are expected due to the traction and do not indicate a complication.

Choice C rationale

Toes that are warm and demonstrate brisk capillary refill are normal findings and do not indicate a complication.

Choice D rationale

Drainage at the pin sites is more relevant to skeletal traction, not Buck’s traction.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Palpate the area behind the ankle bone. This action is correct. The posterior tibial pulse is located behind the medial malleolus (ankle bone), and palpating this area is necessary to assess the pulse.

Choice B rationale

Use the pads of the fingers to feel for the pulse. This action is correct. Using the pads of the fingers provides a more sensitive and accurate assessment of the pulse compared to using the fingertips or thumb.

Choice C rationale

Compare the pulse strength with the other leg. This action is correct. Comparing the pulse strength bilaterally helps identify any discrepancies that may indicate vascular issues.

Choice D rationale

Assess for any swelling or tenderness. This action is incorrect. While assessing for swelling or tenderness is essential in a general physical examination, it is not a specific step in assessing the posterior tibial pulse.

A. Moist skin. B. Blood in the urine. C. Spider angiomas. D. Tarry stools.

Correct Answer is C

Explanation

Choice A rationale

Moist skin is not typically associated with cirrhosis. Cirrhosis often leads to dry, itchy skin due to bile salt accumulation under the skin.

Choice B rationale

Blood in the urine is not a common finding in cirrhosis. This symptom is more indicative of urinary tract issues or kidney problems.

Choice C rationale

Spider angiomas are a common finding in clients with cirrhosis. These are small, dilated blood vessels that appear close to the surface of the skin and are caused by increased estrogen levels due to liver dysfunction.

Choice D rationale

Tarry stools indicate gastrointestinal bleeding, which can occur in cirrhosis due to varices, but it is not a primary expected finding.

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The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

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Correct Answer is C

Explanation

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