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 D

Explanation

According to the Rule of Nines, the percentage of body surface area for different parts of the body is calculated to estimate burn severity. For example, the anterior and posterior aspects of each leg account for 18% each, and the back accounts for 18%. Therefore, the total body surface area burned can be estimated based on these percentages.

A. Medicate for pain. B. Maintain the airway. C. Insert an indwelling urinary catheter. D. Initiate fluid resuscitation.

Correct Answer is B

Explanation

Choice A rationale

While pain management is important, maintaining the airway is the priority intervention for a client with deep partial- and full-thickness burns to the face, chest, abdomen, and upper arms. Burns to the face and chest can cause airway edema and compromise breathing.

Choice B rationale

Maintaining the airway is the priority intervention during the resuscitation phase of injury for a client with burns to the face, chest, abdomen, and upper arms. Airway edema can develop rapidly, and securing the airway is crucial to ensure adequate oxygenation and ventilation.

Choice C rationale

Inserting an indwelling urinary catheter is important for monitoring urine output and fluid balance, but it is not the priority intervention. Airway management takes precedence in this scenario.

Choice D rationale

Initiating fluid resuscitation is essential for managing burn shock and maintaining hemodynamic stability, but maintaining the airway is the priority intervention to ensure the client can breathe adequately.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the burn injury. What percentage of body surface area should the nurse estimate?

Correct Answer is D

Explanation

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?

Correct Answer is B

Explanation

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