The nurse is caring for a client in traction that is immobile. What measures can the nurse provide to prevent further injury and potential infection and promote circulation to the area?
A) Massage bony prominences subject to pressure unless red when pressure relieved.
B) Massage all reddened bony prominences to increase the circulation to the area.
C) Rub alcohol into the skin three times a day to make the skin tougher and less prone to breakdown.
D) Administer protein supplements to the client to avoid the breakdown associated with malnourishment.
A
Feedback:
The nurse should protect the bony prominences from pressure by using pressure-relieving techniques under elbows, heels, and coccyx. Massage bony prominences and skin surfaces subjected to pressure unless they remain red when pressure is relieved. These measures prevent further injury and potential infection and promote circulation to the area Alcohol does not toughen the skin and will cause dryness. Protein supplements must be ordered by the physician and are not necessary for clients in traction.
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