Chapter 17: Traction, Cast Care, And Immobilizatio
Chapter 17: Traction, cast care, and immobilizatio
Exam (elaborations)
Chapter 17: Traction, cast care, and immobilization exam 2024 with 100% correct answers
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Chapter 17: Traction, cast care, and immobilizatio
Institution
Chapter 17: Traction, Cast Care, And Immobilizatio
1. The nurse prepares to place the patient in skin traction. Which is the nurse's main concern before applying the skin traction?
a.Obtain informed consent from patient.
b.Verify that the patient assessment is complete.
c.Prepare a sterile field for pin insertion.
d.Assemble the overhead fram...
Chapter 17: Traction, cast care, and
immobilization
1. The nurse prepares to place the patient in skin traction. Which is the nurse's main concern before
applying the skin traction?
a.Obtain informed consent from patient.
b.Verify that the patient assessment is complete.
c.Prepare a sterile field for pin insertion.
d.Assemble the overhead frame and pulleys. correct answersb.Verify that the patient assessment is
complete.
The priority nursing intervention before the patient goes into skin traction is to ensure that the patient
assessment is completed because the nurse relies on baseline data collected before the procedure to
compare with postprocedure neurovascular and skin assessments.
Without baseline data, the nurse cannot determine whether assessment findings after application of
skin traction are new findings or the patient's baseline status. The healthcare provider provides informed
consent to the patient because he or she performs the procedure. The nurse prepares a sterile field for
pin insertion for application of skeletal traction, not skin traction. Assembling the overhead frame is
generally a function performed by technical personnel. If the nurse must be involved, frame assembly
can wait until after patient assessments are complete.
2. The patient is in Buck's traction for a fractured femur. What should the nurse do to minimize any
muscle spasms of the affected leg?
a.Apply traction gradually, gently, and completely.
b.Assess the affected leg with the "four Ps" criterion.
c.Eliminate potential pressure points from the traction.
d.Ensure unobstructed countertraction to the patient's pelvis. correct answersa.Apply traction gradually,
gently, and completely.
,Muscle spasms associated with a fracture occur because nerves are irritated by bone fragments and
occur more frequently at the initiation of therapy. The nurse attaches weight to the traction slowly,
gradually, and completely to help prevent and eliminate muscle spasms of the affected leg. The weight,
hanging freely, usually creates enough pull on the muscle to release the spasm without increasing pain.
Countertraction to the pelvis is contraindicated in Buck's traction. Assessing the four Ps (pounds, pull,
pulleys, and pressure) ensures that traction is applied correctly. Eliminating potential pressure points is
important but not related to muscle spasms.
3. A patient complains of a slight tingling in the toes of the affected leg 2 hours after the application of
Buck's traction with a foam boot with Velcro straps. Which nursing intervention will prevent potential
complications related to the patient complaint?
a.Apply warm blankets to the feet and reassess.
b.Check the fit of the traction device near the knee.
c.Medicate the patient for pain with an opioid analgesic.
d.Reassure the patient that this is a common complaint. correct answersb.Check the fit of the traction
device near the knee.
Tingling in tissue distal to a potential constriction indicates neurovascular impairment caused by nerve
compression or irritation. The nurse should inspect the patient's knee area because this area is most
likely to be affected by pressure from the traction device. Nursing intervention can prevent a potential
complication of neurovascular impairment such as nerve damage by detecting the source of the pressure
and eliminating the pressure. Warm blankets might be applied to increase regional tissue warmth and
comfort, but they do not address the possible constriction. Although effective for pain, opioid analgesic
agents are ineffective therapy for tingling unless administered in excessive doses that alter the level of
consciousness. Addressing the cause of the tingling is more important. It is inappropriate to assure the
patient that the complaint is common since tingling is a sign of nerve compression and the compression
needs to be alleviated.
4. The nurse assesses the traction boot for a proper fit. Which observation by the nurse verifies that the
patient has a properly fitting Buck's traction boot?
a.The heel rests firmly on the inner heel padding of the boot.
, b.The leg slips out of the boot after applying weight.
c.The pain level increases from a level of 6 to 7 on a scale of 10.
d.The traction boot fits snugly without pressure points. correct answersd.The traction boot fits snugly
without pressure points.
The nurse observes a snug fit without prolonged exposure to pressure for leg protection against traction
forces; the boot maintains adequate neurovascular function and provides effective traction to the
affected region. The nurse should also observe a well-seated heel in the boot and baseline neurovascular
assessment findings. Padding at the heel of a traction boot is contraindicated because the boot is
manufactured to distribute pressure over the heel and leg. If the leg slips out of the boot when weight is
applied, the boot is too loose. After application of the traction, pain should decrease.
5. The nurse assesses a patient 22 hours after skeletal traction was applied to the femur. Which clinical
finding is inconsistent with the patient's baseline data but acceptable to the nurse?
a.A decreased sensation in the affected foot
b.An increase in patient anxiety after procedure
c.Lower leg pallor with a weaker pedal pulse
d.A small amount of clear drainage from the pin sites correct answersd.A small amount of clear drainage
from the pin sites
Clear drainage after pin insertion is an acceptable clinical finding after an invasive procedure because it
reflects the process of drainage produced with punctures. Decreased sensation is consistent with clinical
indicators for neurovascular impairment from nerve compression or irritation. Lower leg pallor and a
weaker pedal pulse indicate compression of the affected leg from edema and the original trauma.
Patient anxiety related to a procedure is more common before the procedure; however, exposure to new
therapy can cause patient anxiety.
6. The nurse is teaching a patient about pin site care. Which of the following should the nurse include in
patient teaching for self-care at home?
a.Use a new sterile applicator for each pin.
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