Question 1

The nurse has asked the unlicensed assistive person (UAP)to provide personal care to the client who is in skin traction and will ensure that UAP knows to place the client in what position?

Accepted Answer

When a client is in skin traction, it is important to maintain proper alignment and avoid disrupting the traction setup. The supine position (lying flat on the back) is typically recommended to ensure the traction is effective and the affected limb is properly supported. This position helps in maintaining the correct alignment and distribution of weight, which is crucial for the traction to work effectively.

Question 2

The nurse is preparing to do pin site care for a client in skeletal traction.It is noted that the site appears red and feels warm to the touch.What actions will the nurse perform in taking care of this situation? Select all that apply.

Accepted Answer

Redness and warmth at a pin site in a patient with skeletal traction could indicate an infection. Therefore, it is important to notify the healthcare provider (A) as they may need to assess the situation and possibly prescribe antibiotics or other treatments. Obtaining a culture and sensitivity specimen from the pin site (C) is a common practice to identify the specific bacteria causing the infection and to determine the most effective antibiotic. Checking the client's vital signs (E) is also important as changes could indicate a systemic response to infection. Refraining from disturbing the crusts around the pin (B) might be considered to prevent further infection risk, but it is not mentioned as a direct action in response to the signs of infection. Removing the client's traction weights (D) is not appropriate without specific orders from a healthcare provider, as it could compromise the traction's effectiveness and the patient's healing process.

Question 3

The nurse is caring for a client who was placed in skeletal traction 48 hours ago for treatment of a serious femur fracture.The nurse will check the client's neurovascular status of the client's affected foot how often?

Accepted Answer

For a patient in skeletal traction, especially within the first few days after injury or surgery, it's important to monitor for complications such as impaired circulation or nerve damage. Checking the neurovascular status (which includes assessments of sensation, movement, and circulation) every 4 hours is a standard practice to ensure any changes are identified and addressed promptly.

Question 4

The nurse is preparing to conduct an hourly assessment of a client who was placed in skin traction approximately 6 hours ago and has been stable since that time.The plan is to check the client's vital signs,pain level and complete what other assessments? Select all that apply.

Accepted Answer

B) Checking the skin integrity of both heels is important to prevent pressure ulcers, especially in immobilized patients.D) Ensuring the traction weight is correctly placed is crucial for the effectiveness of the traction and to prevent further injury.E) Ensuring the client's shoulders and hips are in alignment helps prevent additional strain on the body and maintains proper positioning for healing.

Quiz 9: Mobility

The nurse has asked the unlicensed assistive person (UAP) to provide personal care to the client who is in skin traction and will ensure that UAP knows to place the client in what position?

The nurse is preparing to do pin site care for a client in skeletal traction.It is noted that the site appears red and feels warm to the touch.What actions will the nurse perform in taking care of this situation? Select all that apply.

The nurse is caring for a client who was placed in skeletal traction 48 hours ago for treatment of a serious femur fracture.The nurse will check the client's neurovascular status of the client's affected foot how often?

The nurse is preparing to conduct an hourly assessment of a client who was placed in skin traction approximately 6 hours ago and has been stable since that time.The plan is to check the client's vital signs,pain level and complete what other assessments? Select all that apply.