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

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?

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 is caring for a client with a pressure ulcer. Which of the following interventions is most appropriate?

Correct answer: D

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps prevent infection and promotes healing by ensuring that any contaminants are moved away from the center of the wound. Administering a protein supplement (choice A) or increasing protein intake in the client's diet (choice B) may be beneficial for overall healing but are not the most appropriate interventions specifically for wound care. Increasing IV fluid intake (choice C) is important for hydration but is not the most appropriate intervention for managing a pressure ulcer.

3. A nurse is caring for a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

Correct answer: B

Rationale: The correct answer is B: Hypervigilance. Individuals with PTSD often experience hypervigilance, which involves being overly alert, easily startled, and constantly scanning their environment for potential threats. This heightened state of awareness is a common response to the trauma experienced. Choices A, C, and D are incorrect. Hyperactivity is not typically a primary manifestation of PTSD; restlessness may occur but is not as characteristic as hypervigilance, and although avoidance of social situations can be a symptom of PTSD, hypervigilance is more directly associated with the disorder.

4. 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?

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.

5. During a presentation on basic first aid, a nurse educator evaluates a newly licensed home health nurse's understanding of heat stroke. Which symptom indicates the client has heat stroke?

Correct answer: A

Rationale: The correct answer is A: Hypotension. Heat stroke can lead to hypotension, which is low blood pressure. This is a common symptom of heat stroke and requires immediate intervention. Bradycardia (slow heart rate), clammy skin, and bradypnea (slow breathing) are not typically associated with heat stroke. In heat stroke, the body's temperature regulation system fails, leading to a rapid rise in body temperature, which can cause various symptoms including hypotension.

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