To prevent the complication of skin breakdown in a patient with skeletal traction, the nurse should implement which of the following preventive measures?
A) Do not remove the crusting around the pin insertion site.
B) Encourage the patient to push up with the elbows when repositioning.
C) Encourage the patient to perform ankle and calf muscle exercises once a shift.
D) Assess the pin insertion site every 8 hours.
Ans: D
Feedback: The pin insertion site should be assessed every 8 hours for inflammation and infection. The patient should be encouraged to use the overhead trapeze to shift weight for repositioning. Ankle and calf exercises should be done 10 times an hour while awake.
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