A nurse is caring for a client who has a left femur fracture and is in skeletal traction. The client reports pain due to muscle spasms in the affected leg. Which of the following is an appropriate action by the nurse?

A. Restrict movement of the toes of the affected leg: Limiting toe movement is not necessary unless the toes are being injured. Encouraging gentle movement of the toes can promote circulation and prevent stiffness while the cast sets. Restricting toe motion unnecessarily can increase the risk of complications like decreased perfusion.

B. Dry the cast with a hair dryer set on a warm setting: Using a hair dryer on a warm setting can cause burns or damage the cast material before it fully sets. Casts should be allowed to dry naturally, and heat sources should be avoided during the initial hardening period to prevent injury.

C. Reposition the affected leg using fingertips: Touching or pressing on a newly applied plaster cast can cause indentations, leading to pressure points that may result in skin breakdown or impaired circulation. The cast should be handled minimally and supported rather than manipulated directly.

D. Support the affected leg on a pillow: Elevating and supporting the leg on a pillow helps reduce edema, provides comfort, and promotes proper alignment while the cast sets. This intervention is safe and appropriate during the immediate postoperative or post-cast application period.

Rationale for correct choices

• Client states "It is easier to breathe and I'm not as short of breath": The client’s subjective report of improved breathing reflects a positive response to oxygen therapy, antibiotics, and pulmonary interventions. Decreased dyspnea indicates that oxygenation and lung function are improving. This aligns with expected outcomes for pneumonia management and shows clinical progress.

• Oxygen at 1 L/min via nasal cannula with oxygen saturation of 92%: The reduction in supplemental oxygen from 2 L/min to 1 L/min, while maintaining oxygen saturation above 90%, indicates improved respiratory status and better gas exchange. This demonstrates that the client is stabilizing and responding to therapy, a key indicator of progress.

• Client reports pleuritic chest pain as 3 on a scale of 0 to 10: A decrease in pain from 6/10 to 3/10 shows that inflammation and respiratory effort are improving. Lower pain levels enhance the client’s ability to cough, deep breathe, and participate in pulmonary exercises, supporting recovery.

Rationale for incorrect findings

• Lung sounds still diminished with crackles: Although lung sounds are still diminished with crackles, this finding indicates residual congestion in the lungs rather than full resolution. Crackles can persist for several days after pneumonia begins to improve and do not yet signify complete clinical improvement.

• Cough productive with yellow sputum: The presence of yellow sputum indicates ongoing infection and inflammation. While productive coughing helps clear secretions, the sputum color shows that the infection has not fully resolved, so this is not a definitive indicator of progress.