The nurse is caring for a client who is in skin traction. Which ...

[Chloeellawright]

The nurse is caring for a client who is in skin traction. Which nursing actions are appropriate for this client?
 
  Select all that apply.
 
  1. Assess neurovascular status every 4 hours, once stable.
  2. Place sheep skin under pressure areas.
  3. Massage the skin with lotion or alcohol every 4 hours if redness is noted.
  4. Remove the weight first when removing nonadhesive traction.
  5. Use a slipper bedpan to minimize movement during elimination.

Question 2

The nurse caring for a client in traction inspects the apparatus and determines all is well when noting which finding?
 
  1. The weight is sitting on the floor.
  2. The rope is on the side of the pulley.
  3. The knots are positioned 5 inches from the pulley.
  4. All ropes are intact and connected with slipknots, and short ends are taped.

[kthug]

Answer to Question 1

Correct Answer: 1,2,4,5

Appropriate nursing actions for a client who is in skin traction include assessing neurovascular status every 4 hours, once the client is stable; placing sheep skin under the pressure areas; removing the weight first when removing nonadhesive traction; and using a slipper bedpan to minimize movement during elimination. Although alcohol or lotion rubs and massages are appropriate, they should be completed every 2 hours if redness is noted, not every 4 hours.

Answer to Question 2

Correct Answer: 4

The ropes should be intact and securely attached with slipknots, and the short ends of the rope should be attached with tape, so this is a normal finding. Weights should not touch the floor, because they cannot apply traction unless they are hanging freely. The rope should sit in the groove of the pulley to move freely. Knots should be no closer than 12 inches from the nearest pulley.