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    RN Comprehensive predictor 2023 proctored exam

    A nurse is planning care for a client who has a left hip fracture and is in Buck's traction. Which of the following interventions should the nurse include in the plan of care?

    Explanation & Rationale

    A. Inspect the skin under the boot every 8 hr: Frequent skin assessment is critical for clients in Buck's traction because the traction boot or straps can cause pressure injuries, skin breakdown, or irritation. Checking the skin every 8 hours allows early detection of redness, sores, or areas of compromised circulation and prevents complications associated with prolonged immobility and pressure. B. Assess the client's peripheral circulation every 12 hr: Peripheral circulation should be assessed more frequently than every 12 hours, typically every 1–2 hours initially, to detect early signs of neurovascular compromise such as cyanosis, pallor, coolness, or numbness. Waiting 12 hours could delay identification of circulation issues that may lead to tissue damage or compartment syndrome. C. Ensure the weights are resting on the floor: Traction weights must hang freely to maintain proper alignment and effective traction. Allowing the weights to rest on the floor disrupts the pulling force, reducing traction effectiveness, increasing pain, and potentially worsening fracture displacement. D. Remove the traction to allow the client to use the bathroom: Buck's traction should not be removed for routine activities such as toileting because interrupting traction can cause misalignment, increased pain, and delayed healing. Alternative methods, such as a bedside commode or urinal, should be used while maintaining traction integrity.

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