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. Which of the following statements by a client with human immunodeficiency virus (HIV) does NOT requires further teaching?

A. I can spread this through contact with surfaces, so I need to wear gloves in public.'
B. Because I have HIV, that means I'm an AIDS patient'
C. I need to ensure that I place my needles in a proper needle disposal container.'
D. I can still have unprotected intercourse with my partner since he does not have HIV.'

Correct answer: C

Rationale:

3. The nurse will be using the Braden Scale with each admit to the long-term care center. Which of these will NOT be utilized in a Braden Scale Assessment?

A. Mental state
B. Friction and shear
C. Nutrition
D. Sensory perception

Correct answer: A

Rationale:

4. What is accurate health promotion teaching to prevent ear infection or trauma? (Select all that apply)

A. Blow nose gently without blocking nostrils
B. Wear hearing protection when exposed to loud noise
C. Avoid using cotton-tipped applicators to clean the external ear
D. All of the above

Correct answer: D

Rationale: The correct health promotion teachings to prevent ear infection or trauma include blowing the nose gently without blocking nostrils, wearing hearing protection when exposed to loud noise, and avoiding the use of cotton-tipped applicators to clean the external ear. Blocking one nostril when blowing the nose is incorrect, as it can cause problems. Therefore, choice A is inaccurate. Additionally, using cotton-tipped applicators to clean the external ear can lead to trauma or infection, making choice C a correct preventive measure.