Nursing Care: Traction Monitoring
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Questions and Answers

An older client admitted to the hospital with a hip fracture is placed in Buck's extension traction. The nurse plans to frequently monitor which specimen item?

  • Mental state
  • Range of motion ability
  • Neurovascular status (correct)
  • Temperature
  • Buck's extension traction is applied to an older client following a hip fracture. The nurse explains to the client that this type of traction is:

  • Skeletal traction involving the use of surgically inserted pins
  • Skin traction involving the use of traction attached to the skin and soft tissues (correct)
  • Traction involving the use of a cast
  • Circumferential traction involving the use of a belt around the body
  • A client has Buck's extension traction applied to the right leg. The nurse plans which of the following interventions to prevent complications from the device?

  • Provide pin care once a shift
  • Release the weights on the right leg for range of motion exercises daily
  • Massage the skin of the right leg with lotion every 8 hours
  • Inspect the skin on the right leg at least once every 8 hours (correct)
  • How do you position a client with a left hip fracture in Buck's traction?

    <p>Left calf on pillow from knee to ankle</p> Signup and view all the answers

    A nurse is caring for a patient who has had a hip replacement. The nurse should be most concerned about which of the following findings?

    <p>Temperature of 101.8 F (38.7 C)</p> Signup and view all the answers

    Which statement by the client indicates that the discharge instructions after knee arthroscopy are understood?

    <p>I need to report a fever or site inflammation to my health care provider.</p> Signup and view all the answers

    The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?

    <p>Serous drainage</p> Signup and view all the answers

    A client with a hip fracture asks the nurse why Buck's (extension) traction is being applied before surgery. The nurse provides a response based on which purpose of Buck's traction?

    <p>Provides comfort by reducing muscle spasms and provides fracture immobilization</p> Signup and view all the answers

    The nurse is assigned to care for a client in traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan?

    <p>Check the weights to ensure that they are off of the floor.</p> Signup and view all the answers

    The nurse is preparing a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client?

    <p>Signs of skin breakdown</p> Signup and view all the answers

    The nurse has completed giving discharge instructions to a client who has had total knee replacement (TKR) with a metal prosthesis. The nurse determines that the client understands the instructions if the client verbalizes which statement?

    <p>Other caregivers should be told about the metal implant.</p> Signup and view all the answers

    The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction?

    <p>Weak pedal pulses</p> Signup and view all the answers

    The nurse has delegated the ambulation of a client to the unlicensed assistive personnel (UAP). Which actions by the UAP support a clear understanding of the appropriate steps to carry out this task safely? (Select all that apply)

    <p>Remove clutter that may interfere with ambulation.</p> Signup and view all the answers

    The nurse has completed giving discharge instructions to a client after total knee replacement with a metal prosthesis. The nurse determines that the client needs additional instructions if the client makes which statement?

    <p>Expect changes in the shape of the knee.</p> Signup and view all the answers

    A client has been placed in Buck's extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action?

    <p>Slightly elevating the foot of the bed</p> Signup and view all the answers

    A client is complaining of knee pain. The knee is swollen, reddened, and warm to the touch. The nurse interprets that the client's signs and symptoms are compatible with which conditions? (Select all that apply)

    <p>Inflammation</p> Signup and view all the answers

    Study Notes

    Buck's Extension Traction Overview

    • Buck's extension traction is a type of skin traction applied primarily for lower extremity fractures, especially hip fractures.
    • It involves a belt or boot attached to the skin, creating a pulling force using weights ranging from 5 to 10 pounds.

    Monitoring and Assessment

    • Frequent monitoring of neurovascular status is crucial, particularly in older clients who are at higher risk for complications.
    • Skin integrity must be inspected at least every 8 hours to detect any irritation or breakdown from the traction device.

    Complications and Concerns

    • A postoperative temperature above 101.8 F (38.7 C) in hip replacement patients raises concern for infection.
    • In skeletal traction, the presence of serous drainage at pin sites is generally less concerning than purulent drainage, inflammation, or pain.

    Proper Positioning

    • When positioning a client with a hip fracture in Buck's traction, elevate the affected leg using a pillow under the calf to relieve heel pressure.

    Post-surgical Care

    • After knee arthroscopy, patients should report fever or inflammation, indicating complications that need addressing.
    • During ambulation, ensure patient safety by removing obstacles, assisting with nonskid shoes, and monitoring for dizziness.

    Discharge Instructions

    • Following total knee replacement (TKR), it is essential that caregivers are informed about the patient's metal implant to ensure safety and understanding for future treatment.
    • Signs of bleeding gums or black stools require reporting, as do indicators of infection or increased pain.

    Nursing Actions

    • Weights for traction must always be kept off the floor to ensure effectiveness and prevent injury.
    • Countertraction can be enhanced by slightly elevating the foot of the bed to reduce friction.

    Signs and Symptoms

    • Symptoms such as knee swelling, warmth, and redness may indicate conditions like infection, recent injury, or inflammation, necessitating further assessment and intervention.

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    Description

    This quiz focuses on the vital monitoring of neurovascular status in older clients undergoing Buck's extension traction due to hip fractures. Test your knowledge on the appropriate assessments needed in this situation and ensure optimal patient care.

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