A nurse is caring for a client B. Encourage the client to perform dorsiflexion of the
who has a fractured hip and affected extremity every 2 hr ---The nurse should
was placed in Buck's encourage the client to perform dorsiflexion of the
traction 4 hr ago. Which of affected extremity every 2 hours to assess if the client is
the following actions should experiencing nerve damage. Weakness of dorsiflexion
the nurse take? can indicate peroneal nerve damage. If this occurs, the
nurse should notify the provider immediately.
a. Inspect the client's skin
underneath the boot every Incorrect Answers:
12 hr A. The nurse should inspect the client's skin underneath
b. Encourage the client to the boot for irritation, increased swelling, and skin
perform dorsiflexion of the breakdown every 8 hours.
affected extremity every 2 C. The weights should never be removed without a
hr prescription from the provider. The purpose of the
c. Remove the weights from weights is to decrease muscle spasms as a result of the
the traction while hip fracture.
repositioning the client in D. The ropes of the traction should never be loosened.
bed This can affect the traction and increase the client's
d. Loosen the ropes if the muscle spasms.
client reports muscle
spasms in the affected
extremity
, D. Buck's traction---Buck's traction is used prior to hip
A nurse is caring for a client arthroplasty to maintain alignment and prevent muscle
who has a fractured right spasms prior to surgery.
hip. Which of the following
types of traction should the Incorrect Answers:
nurse expect the client to A. Balanced skeletal traction is used to stabilize fractures
have prior to hip of the femur or pelvis, not the hip. Skeletal traction
arthroplasty surgery? involves the surgical insertion of pins, tongs, wires, or
screws; this is sometimes used to stabilize long bone
a. Balanced skeletal traction and vertebral fractures. B. A pelvic belt is used to treat
b. Pelvic belt back pain and does not provide traction prior to hip
c. Pelvic sling arthroplasty.
d. Buck's traction C. A pelvic sling is used to stabilize pelvic fractures, not
hip fractures.
,A nurse is caring for a client A. "You'll have considerably less pain with the traction in
with a hip fracture who has place."
Buck's extension traction in C. "The traction will help decrease muscle spasms."
place. Which of the D. "The weights act as a pulling force to keep your leg
following pieces of and hip still."
information should the Pain is usually more severe without the traction. Buck's
nurse give the client about extension traction uses weights to help decrease muscle
this type of traction? (Select spasms. Typically, 2.3 to 5.5 kg (5 to 10 lb) of force helps
all that apply.) stabilize the hip and leg preoperatively.
a. "You'll have considerably
less pain with the traction in
place."
b. "You'll have the traction in
place for a week or so."
c. "The traction will help
decrease muscle spasms."
d. "The weights act as a
pulling force to keep your
leg and hip still."
e. "We have to make sure
the weights are just barely
touching the floor."
, A nurse is caring for a client C. With the leg on the affected side abducted---The
who is scheduled to nurse should plan to place the client with the leg
undergo surgery to repair abducted on the affected side postoperatively.
an open hip fracture. In Adduction or external rotation of the leg will cause the
which of the following hip to dislocate.
positions should the nurse
plan to place the client
postoperatively?
a. With the leg on the
affected side adducted
b. With the hip externally
rotated on the affected side
c. With the leg on the
affected side abducted
d. With the hip flexed to 90°
on the affected side
A nurse is assessing a client C. Chest petechiae--- The nurse should identify chest
who has a fractured left petechiae as an indication of fat embolism syndrome.
femur and is in skeletal Clients who have fractures of the long bones such as the
traction. Which of the femur are at increased risk of fat emboli. Fat emboli
following findings should typically occur 12 to 48 hours after the injury when fat
the nurse report to the droplets from the marrow enter into the systemic
provider? circulation and are deposited in the lungs. The nurse
should immediately notify the provider because the
a. Ecchymosis of the thigh client could progress to acute respiratory failure.
b. Serous drainage at the
pin site
c. Chest petechiae
d. Muscle spasms in the left
leg
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