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Difficulty: HardBasic Care and Comfort

A nurse is caring for a client who was placed in balanced suspension skeletal traction for a right femur fracture 24 hours ago. The client reports severe lower back discomfort and requests assistance with repositioning. Which of the following is the most appropriate action by the nurse?

  1. Instruct the client to grasp the overhead trapeze bar and lift the upper torso off the mattress to allow for back care.Answer
  2. B
    Elevate the head of the bed to a 90-degree angle to shift the client's body weight off the lumbar spine and promote comfort.
  3. C
    Assign the unlicensed assistive personnel (UAP) to carefully logroll the client to the left lateral position to alleviate sacral pressure.
  4. D
    Temporarily support and lift the traction weights to relieve tension while sliding the client up toward the head of the bed.

Answer

Instruct the client to grasp the overhead trapeze bar and lift the upper torso off the mattress to allow for back care.
When a client is in balanced suspension skeletal traction, maintaining the continuous line of pull is critical for fracture alignment and healing. Using an overhead trapeze allows the client to safely lift their upper torso off the bed in a straight vertical motion. This action effectively relieves pressure on the back and sacrum, allows the nurse to provide skin care or change linens, and crucially maintains the required alignment of the affected leg without disrupting the therapeutic traction force.

Step-by-Step Solution

1
Analyze the client's prescribed therapy (balanced suspension skeletal traction) and its physiological constraints.
The client must remain in a supine position to maintain a continuous, proper line of pull on the fractured femur.
Altering the position side-to-side or drastically changing the bed angle disrupts the traction mechanics and can cause injury.
2
Evaluate the proposed interventions for both safety and effectiveness in providing basic comfort.
Interventions that involve removing weights, delegating complex positioning to UAP, or severe bed elevation are unsafe or contraindicated.
These actions can cause severe muscle spasms, bone misalignment, or represent improper delegation of care.
3
Identify the intervention that promotes comfort without compromising the traction setup.
Using the overhead trapeze is the safest and most effective choice.
It allows the client to lift their upper body straight up, relieving pressure on the back and sacrum while maintaining the correct alignment of the lower extremity.

Key Concept

Mobility and positioning principles for clients in skeletal traction
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Topics

Basic Care and Comfort

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