The nurse is caring for a client who is in skin traction. Which nursing actions are appropriate for this client?
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 fracture bedpan to minimize movement during elimination.
1, 2, 4, 5
Rationale 1: Appropriate nursing actions for a client who is in skin traction include assessing neurovascular status every 4 hours, once the client is stable.
Rationale 2: Appropriate nursing actions for a client who is in skin traction include placing sheep skin under the pressure areas.
Rationale 3: Although alcohol or lotion rubs and massages are appropriate, they should be completed every 2 hours if redness is noted, not every 4 hours.
Rationale 4: Appropriate nursing actions for a client who is in skin traction include removing the weight first when removing nonadhesive traction.
Rationale 5: Appropriate nursing actions for a client who is in skin traction include using a fracture bedpan to minimize movement during elimination.
Global Rationale: 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 fracture 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.
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