When caring for a patient in skeletal traction, the nurse should complete which 4 interventions?

Choice A rationale

Assessing the range of motion of a severely injured leg is not appropriate during initial evaluation. Movement can worsen the injury or disrupt stabilizing measures such as splints or dressings.

Choice B rationale

Asking the patient to stand or bear weight risks further injury and is contraindicated in cases of visible deformity or massive bleeding.

Choice C rationale

Evaluating skin color helps identify potential ischemia, vascular compromise, or inadequate perfusion. Pallor or cyanosis can indicate significant circulation issues needing urgent care.

Choice D rationale

Paresthesia (tingling or numbness) reflects nerve function and can reveal nerve damage or compromised blood flow, necessitating thorough evaluation.

Choice E rationale

Pain assessment is crucial for identifying the severity of injury and potential complications such as compartment syndrome. Pain disproportionate to the injury suggests complications.

Choice F rationale

Palpating pulses assesses blood flow, ensuring the presence of distal perfusion. Absent or weak pulses require urgent vascular intervention to prevent tissue necrosis.

Choice A rationale

Removing the external fixator for a shower could compromise stabilization of the fracture. External fixators are designed to be left in place to maintain proper alignment and provide structural support for healing bones. Removing the device could introduce unnecessary risks, including increased mobility and potential damage to the fracture site.

Choice B rationale

Prolonged bed rest is not indicated for patients with external fixation devices unless medically necessary. Prolonged immobility can lead to complications such as deep vein thrombosis, muscle atrophy, or joint stiffness. Mobilization should be encouraged as tolerated to support recovery.

Choice C rationale

Proper cleaning of pin insertion sites prevents infection, a major risk with external fixation devices. Using sterile technique to clean the sites daily reduces bacterial colonization. Monitoring for signs of infection such as redness or drainage is critical to avoid osteomyelitis or systemic spread.

Choice D rationale

Prophylactic antibiotics are typically administered perioperatively but are not continued until device removal unless there are specific complications. Prolonged antibiotic use can lead to antimicrobial resistance and should only be used as clinically indicated to prevent or treat infection.