Question

A nurse is caring for a client who has a fractured hip and was placed in continuous Buck's traction 2 hr ago. Which of the following actions should the nurse take?

1) Inspect the client's skin underneath the boot every 12 hr
2) Remove the weights from the traction while repositioning the client in bed
3) Assess the client's circulation every 4 hr
4) Request the client to perform dorsiflexion of the affected extremity every 1 hr

Answer 1

The nurse should assess the client's circulation every 1-2 hours to monitor for any circulatory impairments in the affected extremity.

Step-by-step explanation:

The nurse should inspect the client's skin underneath the boot every 1-2 hours to check for any signs of pressure ulcers or skin breakdown. Continuous skin assessment is necessary to prevent complications. Therefore, option 1 is incorrect.

When repositioning the client in bed, the nurse should not remove the weights from the traction. The weights should remain in place to maintain the proper alignment and immobilization of the fractured hip. Option 2 is incorrect.

The nurse should assess the client's circulation every 1-2 hours to monitor for any circulatory impairments in the affected extremity, such as decreased pulse or color changes. Continuous assessment helps identify any potential problems and allows for timely intervention. Therefore, option 3 is correct.

The nurse should not request the client to perform dorsiflexion of the affected extremity every 1 hour. Dorsiflexion can put unnecessary strain on the fractured hip and hinder the healing process. Option 4 is incorrect.