Traction and Some Amputation Questions

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? 1. Inflammation 2. Serous drainage 3. Pain at a pin site 4. Purulent drainage

2. Serous drainage

The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction? 1. Hypotension 2. Weak pedal pulses 3. Redness at the pin sites 4. Drainage at the pin sites

2. Weak pedal pulses

A client has been placed in Buck's extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action? 1. Using a footboard 2. Providing an overhead trapeze 3. Slightly elevating the foot of the bed 4. Slightly elevating the head of the bed

3. Slightly elevating the foot of the bed

A client is complaining of knee pain. The knee is swollen, reddened, and warm to the touch. The nurse interprets that the client's signs and symptoms are compatible with which conditions? Select all that apply. 1. Infection 2. Recent injury 3. Inflammation 4. Degenerative disease 5. Developmental retardation

1. Infection 2. Recent injury 3. Inflammation

A client with a hip fracture asks the nurse why Buck's (extension) traction is being applied before surgery. The nurse provides a response based on which purpose of Buck's (extension) traction? 1. Allows bony healing to begin before surgery 2. Provides rigid immobilization of the fracture site 3. Lengthens the fractured leg to prevent severing of blood vessels 4. Provides comfort by reducing muscle spasms and provides fracture immobilization

4. Provides comfort by reducing muscle spasms and provides fracture immobilization

How do you position a client with left hip fracture in Buck's traction? a) head of bed raised at 45 degree angle b) left calf on pillow from knee to ankle c) position the left on affected side with pillows between legs d) position the left in the center of the bed with the leg extended

b) left calf on pillow from knee to ankle - elevate the leg with pillow to relieve pressure from the heel of the foot and to improve the effectiveness of the countertraction.

The nurse has delegated the ambulation of a client to the unlicensed assistive personnel (UAP). Which actions by the UAP support a clear understanding of the appropriate steps to carry out this task safely? Select all that apply. 1. Remove clutter that may interfere with ambulation. 2. Assist client in applying nonskid shoes before ambulation. 3. Instruct client to sit up on the bedside and dangle before ambulation. 4. Understand that the client may experience nausea as a normal expectation during ambulation. 5. Observe the client for dizziness during ambulation and report immediately.

1. Remove clutter that may interfere with ambulation. 2. Assist client in applying nonskid shoes before ambulation. 3. Instruct client to sit up on the bedside and dangle before ambulation. 5. Observe the client for dizziness during ambulation and report immediately.

The nurse is assigned to care for a client in traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan? 1. Ensure that the knots are at the pulleys. 2. Check the weights to ensure that they are off of the floor. 3. Ensure that the head of the bed is kept at a 45- to 90-degree angle. 4. Monitor the weights to ensure that they are resting on a firm surface.

2. Check the weights to ensure that they are off of the floor

The nurse is preparing a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? 1. Urinary incontinence 2. Signs of skin breakdown 3. The presence of bowel sounds 4. Signs of infection around the pin sites

2. Signs of skin breakdown

Post-surgical nursing assessment after hip replacement should be principally concerned with the risk of neurovascular complications and the development of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the low grade that is to be expected and should raise concern. Some pain during repositioning and following physical therapy is to be expected and can be managed with analgesics. A small amount of bloody drainage on the surgical dressing is a result of normal healing. The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? 1. "I can resume regular exercise tomorrow." 2. "I can't eat food for the remainder of the day." 3. "I need to stay off the leg entirely for the rest of the day." 4. "I need to report a fever or site inflammation to my health care provider."

4. "I need to report a fever or site inflammation to my health care provider."

A nurse is caring for a patient who has had hip replacement. The nurse should be most concerned about which of the following findings? A. Complaints of pain during repositioning. B. Scant bloody discharge on the surgical dressing. C. Complaints of pain following physical therapy. D. Temperature of 101.8 F (38.7 C).

D. Temperature of 101.8 F (38.7 C). Post-surgical nursing assessment after hip replacement should be principally concerned with the risk of neurovascular complications and the development of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the low grade that is to be expected and should raise concern. Some pain during repositioning and following physical therapy is to be expected and can be managed with analgesics. A small amount of bloody drainage on the surgical dressing is a result of normal healing.

. A client has Buck's extension traction applied to the right leg. The nurse plans which of the following interventions to prevent complications from the device? a) provide pin care once a shift b) massage the skin of the right leg with lotion every 8 hours c) inspect the skin on the right leg at least once every 8 hours d) release the weights on the right leg for range of motion exercises daily

c) inspect the skin on the right leg at least once every 8 hours Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically ordered by the physician. There are no pins to care for with skin traction.

. Buck's extension traction is applied to an older client following a hip fracture. The nurse explains to the client that this type of traction is: a) traction involving the use of a cast b) skeletal traction involving the use of surgically inserted pins c) circumferential traction involving the use of a belt around the body d) skin traction involving the use of traction attached to the skin and soft tissues

d) skin traction involving the use of traction attached to the skin and soft tissues - Buck's extension traction is a form of skin traction and involves the use of a belt or boot that is attached to the skin and soft tissues. The purpose of this type of traction is to decrease painful muscle spasms that accompany fractures. The weight that is used as a pulling force is limited (usually 5 to 10 pounds) to prevent injury to the skin. Options A, B, and C are incorrect descriptions.

The nurse has completed giving discharge instructions to a client after total knee replacement with a metal prosthesis. The nurse determines that the client needs additional instructions if the client makes which statement? 1. Report bleeding gums or tarry stools. 2. Report fever, redness, or increased pain. 3. Expect changes in the shape of the knee. 4. Tell future caregivers about the metal implant.

3. Expect changes in the shape of the knee

The nurse has completed giving discharge instructions to a client who has had total knee replacement (TKR) with a metal prosthesis. The nurse determines that the client understands the instructions if the client verbalizes which statement? 1. Fever, redness, or increased pain is expected. 2. Changes in the shape of the knee are expected. 3. Other caregivers should be told about the metal implant. 4. Bleeding gums or black stools may occur, but this is normal.

3. Other caregivers should be told about the metal implant

. An older client admitted to the hospital with a hip fracture is placed in Buck's extension traction. The nurse plans to frequently monitor which specimen item? a) temperature b) mental state c) neurovascular status d) range of motion ability

c) neurovascular status - The neurovascular status of the extremity of the client in Buck's extension traction must be assessed frequently. Older clients are especially at risk for neurovascular compromise because many older clients already have disorders that affect the peripheral vascular system. Although the client's temperature is monitored, it is not specific to the use of Buck's extension traction. Although clients in some types of traction do become depressed after a few days or weeks, Buck's extension traction is usually used preoperatively, which typically involves a few hours or 1 to 2 days, at the most. Range of motion of the involved leg is contraindicated in hip fractures.