A client who is hospitalized after a left hip fracture is ...

[elizabeth18]

A client who is hospitalized after a left hip fracture is scheduled for surgery late this afternoon. After receiving report, the nurse evaluates the Buck traction applied by a new physical therapist.
 
  Which finding indicates that the traction is correctly applied?
  A) Foam boot covers the right lower leg from the knee down.
  B) 20-pound weights are connected to the bottom of a foam boot.
  C) Weights are supported by a stool at the end of the bed.
  D) The left knee and hip are in alignment above the foam boot.

Question 2

A nurse is caring for a client who was recently admitted for treatment of cirrhosis. The client is currently experiencing BP of 200/100 mmHg, +3 pitting edema, and shortness of breath.
 
  Which nursing diagnosis should the nurse select as a priority for this client?
  A) Excess Fluid Volume
  B) Ineffective Tissue Perfusion
  C) Deficient Fluid Volume
  D) Impaired Skin Integrity

[reversalruiz]

Answer to Question 1

Answer: D

The correct placement of Buck traction permits the left knee and hip to align. Buck traction is skin traction which does not tolerate heavy weights. Usually 5-pound weights are used. Twenty-pound weights are used on skin traction. Weights always hang free from a pulley and are never supported by a stool at the end of the bed. A foam boot covers the affected leg, the left leg, not the right.

Answer to Question 2

Answer: A

The client experiencing shortness of breath, edema, and hypertension should have a care plan for fluid volume excess. Hypertension, shortness of breath, and edema are manifestations of fluid excess. Hypotension and dry mucous membranes are associated with deficient fluid volume. Ineffective Tissue Perfusion would be the appropriate diagnosis for a client experiencing cyanosis or tissue necrosis. Edema can cause an alteration in skin integrity, but there is no evidence of such problems with this client.

[elizabeth18]

Gracias!

[phuda]

Excellent