what is a priority intervention when caring for a client in bucks traction

ATI RN

Multi Dimensional Care | Final Exam

1. What is a priority intervention when caring for a client in Buck’s traction?

A. Adjust the size of the traction weights PRN as needed
B. Discontinue the traction once the client has pain relief
C. Ensure the traction weights rest on the floor
D. Assess skin integrity

Correct answer: D

Rationale: The correct answer is to assess skin integrity when caring for a client in Buck’s traction. This is crucial as it helps prevent pressure ulcers and other skin-related complications. Choice A is incorrect because changing the size of the traction weights should be done based on healthcare provider orders, not as needed. Choice B is incorrect because discontinuing traction should be done only under healthcare provider direction, not solely based on pain relief. Choice C is incorrect as allowing the traction weights to rest on the floor is not a priority intervention compared to assessing skin integrity.

2. The client has been asked to perform weight-bearing exercises three times a week. The client admits to not doing the recommended exercises. What is the most appropriate response by the nurse?

A. I walk 3 miles every day. Would you like to join me?
B. Tell me more about your experience with these exercises.
C. My dad never exercised. He fell and broke his hip. Is that your goal?
D. You should be doing these exercises.

Correct answer: B

Rationale: The most appropriate response by the nurse is to ask the client to elaborate on their experience with the exercises. By doing so, the nurse can gain insight into any barriers the client may be facing and work together to find solutions to improve adherence. Choice A is not appropriate as it doesn't address the client's situation. Choice C is not relevant and may induce fear in the client. Choice D is directive and does not promote open communication or understanding of the client's perspective.

3. What statement by the client indicates a correct understanding of the timing of progression of human immunodefiency virus (HIV) to acquired immunodeficiency syndrome?

A. "Sexually transmitted infections will not make AIDS develop faster"?
B. "My diet does not influence the progression of HIV to AIDS"?
C. "If I practice medication, I may develop AIDS faster."?
D. "IF I am re-exposed to HIV, the progression to AIDS may be faster,"?

Correct answer: D

Rationale:

4. A nurse is assessing a client with hallux valgus. What is another term for this assessment finding?

A. Thoracic deformity
B. A bunion
C. A corn
D. Metacarpal involvement

Correct answer: B

Rationale: Hallux valgus is commonly known as a bunion, which is a bony bump that forms on the joint at the base of the big toe. A) Thoracic deformity is unrelated to hallux valgus. C) A corn is a thickened area of skin on the foot, not synonymous with hallux valgus. D) Metacarpal involvement refers to the hand, not the foot where hallux valgus occurs.