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.
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.
You might also like to view...
The patient most likely to need a mechanical assist device for heart failure will have which stage of heart failure?
A) Stage A B) Stage B C) Stage C D) Stage D
A young adult client notes height as "5 feet 11 inches" and weight as "200 lbs." Upon assessment, the client is found to be 5 feet 9 inches tall with a weight of 225 lbs. Which is the most likely cause of this discrepancy?
1. The client does not have a scale at home. 2. The client may have an image of self that is inconsistent with actual findings. 3. The client did not want to tell the truth. 4. The client is trying to hide a chronic illness.
Janice is 49 years old, is married, and has two teenage children. Over the last year, her periods tended to be irregular and heavier than usual
She also noticed intercourse was becoming more painful for her, and her interest in sex declined. She knew her mother was 51 when she reached menopause, and Janice was concerned about having the mood swings and hot flashes her mother had experienced. She phoned some of her friends to seek their advice. Some said she should try hormone therapy, while others said it was not a good idea at all. Other friends said she should use remedies like red clover tea and soy isoflavone supplements. Janice decided her best bet was to go to the local women's health care clinic to discuss her options with a nurse. Using the data collected by the Women's Health Initiative and the Nurses' Health Study, why are some women at an increased risk for CHD and others are at a decreased risk when hormone therapy is prescribed? Why are alternative methods like red clover and some plant oils being promoted for the menopausal woman? What are the changes that occur in a woman's reproductive organs when estrogen levels decline? How does estrogen affect bone growth during puberty? Why are postmenopausal women at risk for osteoporosis?
After a bone marrow aspiration, the client has bruising at the site (left iliac crest). What is the nurse's best action?
A. Document the finding as the only action. B. Position the client on his/her right side. C. Apply an ice pack to the site. D. Notify the physician.