Question

A client in skeletal traction has a nursing diagnosis of Impaired Tissue Integrity: Related to puncture wound; pins.

Answer 1

Answer:

The client traction weights are resting on the floor.

Explanation:

The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. The client's blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill time.

DIF: Applying/Application REF: 1060 KEY: Fracture| traction

MSC: Integrated Process: Communication and Documentation

NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care