a nurse is caring for a client who is in bucks traction which of the following actions should the nurse take

ATI LPN

ATI NCLEX PN Predictor Test

1. A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take?

A. Remove the weights
B. Ensure the weights hang freely
C. Increase the traction force
D. Loosen the ropes

Correct answer: B

Rationale: The correct action the nurse should take when caring for a client in Buck's traction is to ensure the weights hang freely. This is essential to maintain proper alignment and ensure the effectiveness of Buck's traction. Removing the weights (Choice A) would be incorrect and could compromise the treatment. Increasing the traction force (Choice C) can lead to excessive pressure and potential harm to the client. Loosening the ropes (Choice D) would also be inappropriate as it can disrupt the traction's effectiveness and alignment.

2. A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?

A. Change the appliance daily
B. Clean the stoma once a day
C. Avoid changing the appliance for a week
D. Change the appliance twice each week

Correct answer: D

Rationale: The correct answer is to change the appliance twice each week. Changing the appliance too frequently can irritate the skin around the stoma, while not changing it often enough can lead to infection. Changing the appliance twice a week helps to maintain hygiene without causing irritation. Choices A, B, and C are incorrect because changing the appliance daily can cause irritation, cleaning the stoma once a day may not be sufficient for proper hygiene, and avoiding changing the appliance for a week can increase the risk of infection and skin breakdown.

3. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

A. A client with pneumonia who had new onset of confusion
B. A client with diabetes who had low blood sugar overnight
C. A client with a leg fracture who needs pain medication
D. A client whose urinary output was 100 mL for the past 12 hours

Correct answer: A

Rationale: The correct answer is A. New confusion in a client with pneumonia could indicate hypoxia or a worsening condition, requiring immediate attention. Option B, a client with diabetes having low blood sugar overnight, is a concerning condition but not as urgent as potential hypoxia. Option C, a client with a leg fracture needing pain medication, and option D, a client with decreased urinary output, are important but do not take precedence over addressing a potentially critical respiratory issue.

4. What are the nursing interventions for a patient experiencing hypoglycemia?

A. Administer glucose or dextrose and monitor blood sugar levels
B. Monitor vital signs and provide a high-carbohydrate snack
C. Monitor for sweating and confusion
D. Provide insulin and assess for hyperglycemia

Correct answer: A

Rationale: The correct answer is A. Administering glucose or dextrose is a crucial nursing intervention for a patient experiencing hypoglycemia as it helps to quickly raise blood sugar levels. Monitoring blood sugar levels is essential to ensure that the patient's glucose levels normalize. Choice B is incorrect because providing a high-carbohydrate snack may not be sufficient to rapidly raise blood sugar levels in severe hypoglycemia. Choice C is incorrect because while monitoring for sweating and confusion is important in hypoglycemia, it is not a direct nursing intervention. Choice D is incorrect as providing insulin would lower blood sugar levels further, worsening hypoglycemia.

5. What are the primary causes of respiratory acidosis?

A. Hypoventilation and lung disease
B. Hyperventilation and pneumonia
C. Increased oxygen saturation and tachypnea
D. Dehydration and hypoxia

Correct answer: A

Rationale: The correct answer is A: Hypoventilation and lung disease. Respiratory acidosis occurs when there is an accumulation of CO2 in the body due to inadequate ventilation. Hypoventilation, which reduces the elimination of CO2, and lung diseases that impair gas exchange are the primary causes. Choice B is incorrect because hyperventilation, not hypoventilation, leads to respiratory alkalosis, not acidosis. Choice C is incorrect because increased oxygen saturation and tachypnea do not directly cause respiratory acidosis. Choice D is incorrect as dehydration and hypoxia do not typically lead to respiratory acidosis.