A patient who has a displaced mid-shaft fracture of the left femur and is in balanced suspension skeletal traction with 35 pounds of weights is experiencing calf pain with right foot dorsiflexion. Which action should the nurse take?
a. Notify the RN.
b. Check the traction setup.
c. Reduce 5 pounds of weight.
d. Encourage dorsiflexion more frequently.
ANS: A
Calf pain on dorsiflexion can indicate a thrombophlebitis (Homan's sign). The RN should be informed. B. The nurse should not take the time now to check the traction setup. C. Traction weight cannot be reduced without a physician's order. D. The patient should not be encouraged to exercise the limb now since a thrombophlebitis might be present.
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