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Difficulty: HardBasic Care and Comfort

A nurse is providing morning care for a client who is in balanced suspension skeletal traction for a fractured right femur. Which action by the nurse demonstrates the correct application of basic care and comfort principles?

  1. A
    Delegating the assessment of the client's sacral skin integrity to the unlicensed assistive personnel (UAP) during the bed bath
  2. Assisting the client to use an overhead trapeze bar to lift the upper body off the bed for a linen changeAnswer
  3. C
    Lifting the traction weights manually to relieve tension while sliding the client higher up in the bed
  4. D
    Turning the client onto their unaffected left side every two hours to relieve sacral pressure and promote comfort

Answer

The correct answer is assisting the client to use an overhead trapeze bar to lift their upper body off the bed for a linen change.
The use of an overhead trapeze bar allows a client in balanced suspension skeletal traction to safely lift their upper body off the bed. This facilitates independent movement, assists with bedpan placement, and allows the nurse to perform back care and linen changes without disrupting the continuous line of pull required for fracture alignment.

Step-by-Step Solution

1
Analyze the client's specific medical intervention and its physical constraints.
The client is in balanced suspension skeletal traction, which requires continuous, uninterrupted pull to maintain bone alignment.
Basic care must be adapted to avoid disrupting the traction setup or causing injury.
2
Evaluate each nursing action against the safety rules for skeletal traction and general nursing scope of practice.
Lifting weights and turning side-to-side disrupt traction. Delegating assessment is outside the UAP scope of practice. Using a trapeze bar safely facilitates care.
Identifying contraindicated actions eliminates incorrect choices based on foundational basic care and delegation principles.
3
Select the action that promotes basic care and comfort while maintaining the safety and integrity of the traction.
Assisting the client to use an overhead trapeze bar is the correct action.
This is the only evidence-based, safe action for a client with skeletal traction who requires hygiene and linen changes.

Key Concept

Basic Care and Positioning for Clients in Skeletal Traction
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Topics

Basic Care and Comfort

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