Indicate four assessment findings which require immediate follow-up.

Choice A rationale

Performing neurovascular assessments on the affected extremity helps identify potential complications such as ischemia or nerve damage. This includes checking circulation, sensation, and movement regularly to ensure proper function and prevent permanent injury.

Choice B rationale

Skeletal traction relies on the tension created by weights hanging freely to maintain proper alignment of the bone. If weights lay flat on the ground, the traction effect is lost, undermining the therapeutic purpose of the intervention.

Choice C rationale

Observing pin sites for signs of infection is crucial in preventing complications like osteomyelitis. Regular monitoring ensures early detection and management of redness, swelling, or discharge, which can compromise treatment outcomes.

Choice D rationale

Assessing skin for signs of breakdown is essential in immobile patients receiving skeletal traction. Prolonged pressure and reduced mobility increase the risk of pressure ulcers, necessitating vigilant skin checks and preventive measures.

Choice E rationale

Applying a boot directly to the skin is not appropriate in skeletal traction. Devices must be used correctly and securely without creating additional pressure points or compromising the treatment's effectiveness.

Choice F rationale

Providing pin site care prevents infections and maintains the integrity of the pin and surrounding tissue. This involves cleaning the area and using antiseptics, which are standard practices in skeletal traction care.

Choice A rationale

Checking blood pressure does not directly address the faint pulses and cool foot. While hypotension could contribute to peripheral perfusion issues, the signs described more likely indicate compartment syndrome, which requires urgent action.

Choice B rationale

Repositioning the leg might provide some comfort but does not alleviate the potential compartment syndrome. Elevation could worsen ischemia by reducing arterial blood flow.

Choice C rationale

Compartment syndrome is a medical emergency caused by increased pressure within a muscle compartment. This pressure compromises circulation and tissue viability. The nurse must notify the health care provider immediately to prevent permanent damage.

Choice D rationale

Assessing the incision for redness delays addressing the critical signs of potential compartment syndrome. Redness indicates infection, but faint pulses and a cool extremity necessitate more urgent evaluation.