A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4 hr ago.
Which of the following actions should the nurse take?
a. Inspect the client's skin underneath the boot every 12 hr
b. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr
c. Remove the weights from the traction while repositioning the client in bed
d. Loosen the ropes if the client reports muscle spasms in the affected extremity -c0rrect
answer B. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr ---
The nurse should encourage the client to perform dorsiflexion of the affected extremity every 2
hours to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate
peroneal nerve damage. If this occurs, the nurse should notify the provider immediately.
Incorrect Answers:
A. The nurse should inspect the client's skin underneath the boot for irritation, increased
swelling, and skin breakdown every 8 hours.
C. The weights should never be removed without a prescription from the provider. The purpose
of the weights is to decrease muscle spasms as a result of the hip fracture.
D. The ropes of the traction should never be loosened. This can affect the traction and increase
the client's muscle spasms.
A nurse is caring for a client who has a fractured right hip. Which of the following types of
traction should the nurse expect the client to have prior to hip arthroplasty surgery?
a. Balanced skeletal traction
b. Pelvic belt
c. Pelvic sling
d. Buck's traction -c0rrect answer D. Buck's traction---Buck's traction is used prior to hip
arthroplasty to maintain alignment and prevent muscle spasms prior to surgery.
Incorrect Answers:
,A. Balanced skeletal traction is used to stabilize fractures of the femur or pelvis, not the hip.
Skeletal traction involves the surgical insertion of pins, tongs, wires, or screws; this is sometimes
used to stabilize long bone and vertebral fractures. B. A pelvic belt is used to treat back pain and
does not provide traction prior to hip arthroplasty.
C. A pelvic sling is used to stabilize pelvic fractures, not hip fractures.
A nurse is caring for a client with a hip fracture who has Buck's extension traction in place.
Which of the following pieces of information should the nurse give the client about this type of
traction? (Select all that apply.)
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." -c0rrect answer A.
"You'll have considerably less pain with the traction in place."
C. "The traction will help decrease muscle spasms."
D. "The weights act as a pulling force to keep your leg and hip still."
Pain is usually more severe without the traction. Buck's extension traction uses weights to help
decrease muscle spasms. Typically, 2.3 to 5.5 kg (5 to 10 lb) of force helps stabilize the hip and
leg preoperatively.
A nurse is caring for a client who is scheduled to undergo surgery to repair an open hip fracture.
In which of the following 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 -c0rrect answer C. With the leg on the affected
side abducted---The nurse should plan to place the client with the leg abducted on the affected
side postoperatively. Adduction or external rotation of the leg will cause the hip to dislocate.
,A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of
the following findings should the nurse report to the provider?
a. Ecchymosis of the thigh
b. Serous drainage at the pin site
c. Chest petechiae
d. Muscle spasms in the left leg -c0rrect answer C. Chest petechiae--- The nurse should identify
chest petechiae as an indication of fat embolism syndrome. Clients who have fractures of the
long bones such as the femur are at increased risk of fat emboli. Fat emboli typically occur 12 to
48 hours after the injury when fat droplets from the marrow enter into the systemic circulation
and are deposited in the lungs. The nurse should immediately notify the provider because the
client could progress to acute respiratory failure.
A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur
fracture. Which of the following actions should the nurse include in the client's plan of care?
a. Offering the client a diet high in fluid and fiber
b. Encouraging active range of motion of the affected leg
c. Removing the weights prior to repositioning the client
d. Inspecting pin sites every 24 hr for drainage -c0rrect answer A. Offering the client a diet high
in fluid and fiber---- A client who is immobile is at risk of constipation. The nurse should
encourage a diet high in fluid and fiber to promote gastrointestinal function.
Incorrect Answers:
B. Active range of motion of the unaffected limbs is encouraged to prevent muscle wasting;
however, active range of motion of a limb in traction is not feasible, as the traction apparatus
limits mobility.
C. Once the weights are in place, the nurse should not remove them.
D. The nurse should plan to inspect the client's pin sites at least every 8 to 12 hours due to the
risk of infection.
, A nurse is caring for a client who is in skeletal traction following a femur fracture. On entering,
the nurse finds that the client has slid toward the foot of the bed, and the traction weight is
resting on the floor. Which of the following actions should the nurse take?
a. Remove the weight temporarily to reposition the client to the correct alignment in bed
b. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely
c. Lift the rope off the pulley while the client rocks back and forth to reposition himself
d. Lift the weight manually while another staff member moves the client up in bed -c0rrect
answer B. Have the client use a trapeze to pull himself up while ensuring the weight hangs
freely---The nurse should ensure that traction weight is hanging freely. The client can use an
overhead trapeze bar to move up in bed, or the nurse can assist the client while making sure to
maintain proper alignment of the extremity.
A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The
nurse notes in the documentation that the AP obtained the client's axillary temperature;
however, the nurse wanted an oral temperature. The nurse should identify which of the
following rights of delegation should have prevented this situation from occurring?
a. Right task
b. Right circumstance
c. Right person
d. Right communication -c0rrect answer D. Right communication--- The situation could have
been avoided if the right communication was given by the nurse to the AP. The right
communication entails providing clear, concise instructions regarding the task, including the
objective, limits, and expectations.
A client who reports shortness of breath requests the nurse's help in changing positions. After
repositioning the client, which of the following actions should the nurse take next?
a. Encourage the client to take deep breaths
b. Observe the rate, depth, and character of the client's respirations
c. Prepare to administer oxygen
Which of the following actions should the nurse take?
a. Inspect the client's skin underneath the boot every 12 hr
b. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr
c. Remove the weights from the traction while repositioning the client in bed
d. Loosen the ropes if the client reports muscle spasms in the affected extremity -c0rrect
answer B. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr ---
The nurse should encourage the client to perform dorsiflexion of the affected extremity every 2
hours to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate
peroneal nerve damage. If this occurs, the nurse should notify the provider immediately.
Incorrect Answers:
A. The nurse should inspect the client's skin underneath the boot for irritation, increased
swelling, and skin breakdown every 8 hours.
C. The weights should never be removed without a prescription from the provider. The purpose
of the weights is to decrease muscle spasms as a result of the hip fracture.
D. The ropes of the traction should never be loosened. This can affect the traction and increase
the client's muscle spasms.
A nurse is caring for a client who has a fractured right hip. Which of the following types of
traction should the nurse expect the client to have prior to hip arthroplasty surgery?
a. Balanced skeletal traction
b. Pelvic belt
c. Pelvic sling
d. Buck's traction -c0rrect answer D. Buck's traction---Buck's traction is used prior to hip
arthroplasty to maintain alignment and prevent muscle spasms prior to surgery.
Incorrect Answers:
,A. Balanced skeletal traction is used to stabilize fractures of the femur or pelvis, not the hip.
Skeletal traction involves the surgical insertion of pins, tongs, wires, or screws; this is sometimes
used to stabilize long bone and vertebral fractures. B. A pelvic belt is used to treat back pain and
does not provide traction prior to hip arthroplasty.
C. A pelvic sling is used to stabilize pelvic fractures, not hip fractures.
A nurse is caring for a client with a hip fracture who has Buck's extension traction in place.
Which of the following pieces of information should the nurse give the client about this type of
traction? (Select all that apply.)
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." -c0rrect answer A.
"You'll have considerably less pain with the traction in place."
C. "The traction will help decrease muscle spasms."
D. "The weights act as a pulling force to keep your leg and hip still."
Pain is usually more severe without the traction. Buck's extension traction uses weights to help
decrease muscle spasms. Typically, 2.3 to 5.5 kg (5 to 10 lb) of force helps stabilize the hip and
leg preoperatively.
A nurse is caring for a client who is scheduled to undergo surgery to repair an open hip fracture.
In which of the following 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 -c0rrect answer C. With the leg on the affected
side abducted---The nurse should plan to place the client with the leg abducted on the affected
side postoperatively. Adduction or external rotation of the leg will cause the hip to dislocate.
,A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of
the following findings should the nurse report to the provider?
a. Ecchymosis of the thigh
b. Serous drainage at the pin site
c. Chest petechiae
d. Muscle spasms in the left leg -c0rrect answer C. Chest petechiae--- The nurse should identify
chest petechiae as an indication of fat embolism syndrome. Clients who have fractures of the
long bones such as the femur are at increased risk of fat emboli. Fat emboli typically occur 12 to
48 hours after the injury when fat droplets from the marrow enter into the systemic circulation
and are deposited in the lungs. The nurse should immediately notify the provider because the
client could progress to acute respiratory failure.
A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur
fracture. Which of the following actions should the nurse include in the client's plan of care?
a. Offering the client a diet high in fluid and fiber
b. Encouraging active range of motion of the affected leg
c. Removing the weights prior to repositioning the client
d. Inspecting pin sites every 24 hr for drainage -c0rrect answer A. Offering the client a diet high
in fluid and fiber---- A client who is immobile is at risk of constipation. The nurse should
encourage a diet high in fluid and fiber to promote gastrointestinal function.
Incorrect Answers:
B. Active range of motion of the unaffected limbs is encouraged to prevent muscle wasting;
however, active range of motion of a limb in traction is not feasible, as the traction apparatus
limits mobility.
C. Once the weights are in place, the nurse should not remove them.
D. The nurse should plan to inspect the client's pin sites at least every 8 to 12 hours due to the
risk of infection.
, A nurse is caring for a client who is in skeletal traction following a femur fracture. On entering,
the nurse finds that the client has slid toward the foot of the bed, and the traction weight is
resting on the floor. Which of the following actions should the nurse take?
a. Remove the weight temporarily to reposition the client to the correct alignment in bed
b. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely
c. Lift the rope off the pulley while the client rocks back and forth to reposition himself
d. Lift the weight manually while another staff member moves the client up in bed -c0rrect
answer B. Have the client use a trapeze to pull himself up while ensuring the weight hangs
freely---The nurse should ensure that traction weight is hanging freely. The client can use an
overhead trapeze bar to move up in bed, or the nurse can assist the client while making sure to
maintain proper alignment of the extremity.
A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The
nurse notes in the documentation that the AP obtained the client's axillary temperature;
however, the nurse wanted an oral temperature. The nurse should identify which of the
following rights of delegation should have prevented this situation from occurring?
a. Right task
b. Right circumstance
c. Right person
d. Right communication -c0rrect answer D. Right communication--- The situation could have
been avoided if the right communication was given by the nurse to the AP. The right
communication entails providing clear, concise instructions regarding the task, including the
objective, limits, and expectations.
A client who reports shortness of breath requests the nurse's help in changing positions. After
repositioning the client, which of the following actions should the nurse take next?
a. Encourage the client to take deep breaths
b. Observe the rate, depth, and character of the client's respirations
c. Prepare to administer oxygen
