When providing care to a client in skeletal traction, what action would be included in the nurse's plan of care?

Choice A reason: Providing cast care to bilateral lower extremities is not an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is not relevant to the type of traction. Skeletal traction involves the insertion of pins, wires, or screws into the bone, and does not require a cast. Cast care is more applicable to clients in plaster or fiberglass casts.

Choice B reason: Instituting measures to prevent skin breakdown is an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is a potential complication of prolonged immobilization and pressure. The nurse should inspect the skin regularly, change the bed linens frequently, use pressure-relieving devices, and encourage the client to shift positions as much as possible.

Choice C reason: Cleaning the pins every hour with peroxide to prevent infection is not an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is excessive and harmful. The nurse should follow the facility's protocol for pin site care, which usually involves cleaning the pins once or twice a day with a mild antiseptic solution, such as chlorhexidine or saline. Peroxide is not recommended, as it can damage the tissue and delay the healing.

Choice D reason: Placing the client on contact precautions is not an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is not indicated for this type of traction. Contact precautions are used for clients who have infections that can be transmitted by direct or indirect contact, such as MRSA, VRE, or C. difficile. Skeletal traction does not pose a high risk of infection, unless there is a pin site infection or osteomyelitis.

Choice E reason: Maintaining proper alignment and position of the traction is an action that would be included in the nurse's plan of care for a client in skeletal traction, as it is essential for the effectiveness and safety of the traction. The nurse should ensure that the traction is applied correctly, that the weights are hanging freely, that the ropes are not twisted or frayed, and that the pulleys are not obstructed. The nurse should also avoid lifting or moving the weights, as it can alter the traction force and cause complications.

Choice A reason: A 24-gauge catheter is appropriate for a small and fragile vein of a 12-month-old infant. It minimizes the risk of damaging the vein and ensures the comfort of the infant during IV therapy.

Choice B reason: Starting an IV in the infant's foot is not the first choice due to the risk of movement dislodging the catheter. The hand or the antecubital fossa are preferred sites for IV insertion in infants.

Choice C reason: While it is important to cover the IV insertion site, an opaque dressing is not necessary. A transparent dressing is preferred as it allows for continuous visibility of the site for signs of infection or phlebitis.

Choice D reason: The IV site should not be routinely changed every 3 days. It should be changed based on clinical indications such as signs of infection, infiltration, or phlebitis, or if the IV becomes dislodged.