A nurse is caring for a client in Buck's skin traction. Which of ...

[cnetterville]

A nurse is caring for a client in Buck's skin traction. Which of the following indicates a need for corrective action?
 
  A) The traction weights are touching the floor.
  B) The traction is being applied continuously.
  C) The countertraction is opposite to the pull of traction.
  D) The client's mobility is limited.

Question 2

When giving a tepid bed bath to an African American who has high fever, the nurse notices brown discoloration on the washcloth. What should the nurse's reaction be in this case?
 
  A) Assume that it is due to high fever.
  B) Educate the client about personal hygiene.
  C) Consider it to be normal in the client.
  D) Bathe the client again, assuming it is dirt.

[Briannahope]

Answer to Question 1

A
Feedback:
To maintain an effective traction, the traction weight should be suspended without interference and not touching the floor. The nurse should keep the traction applied continuously to get the desired effect unless there are medical orders otherwise. The countertraction must be maintained in a direction opposite to the pull of traction for effective traction. The client's position is limited as per the standards of care to avoid any interference in the traction pull and counterpull action.

Answer to Question 2

C
Feedback:
The brown discoloration on the washcloth is normal in dark-skinned clients, due to the shedding of dead cells that are brown in color. The nurse should consider it as normal because it is common in the specified culture. Fever does not lead to brown discoloration. To educate the client about personal hygiene, having made the assumption that it is dirt, may likewise not be appropriate, as the client may feel offended. Also, the nurse need not bathe the client again.