Chapter 17: Traction, Cast Care, and Immobilization Devices

Chapter 17: Traction, Cast Care, and Immobilization Devices

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse prepares to place the patient in skin traction. Which is the nurse’s main concern before applying the skin traction?

a.	Obtain informed consent from patient.
b.	Verify that the patient assessment is complete.
c.	Prepare a sterile field for pin insertion.
d.	Assemble the overhead frame and pulleys.

 

 

ANS:  B

The priority nursing intervention before the patient goes into skin traction is to ensure that the patient assessment is completed because the nurse relies on baseline data collected before the procedure to compare with postprocedure neurovascular and skin assessments. Without baseline data, the nurse cannot determine whether assessment findings after application of skin traction are new findings or the patient’s baseline status. The healthcare provider provides informed consent to the patient because he or she performs the procedure. The nurse prepares a sterile field for pin insertion for application of skeletal traction, not skin traction. Assembling the overhead frame is generally a function performed by technical personnel. If the nurse must be involved, frame assembly can wait until after patient assessments are complete.

 

DIF:    Cognitive Level: Apply                   REF:   Page 452

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Planning

 

2. The patient is in Buck’s traction for a fractured femur. What should the nurse do to minimize any muscle spasms of the affected leg?

a.	Apply traction gradually, gently, and completely.
b.	Assess the affected leg with the “four Ps” criterion.
c.	Eliminate potential pressure points from the traction.
d.	Ensure unobstructed countertraction to the patient’s pelvis.

 

 

ANS:  A

Muscle spasms associated with a fracture occur because nerves are irritated by bone fragments and occur more frequently at the initiation of therapy. The nurse attaches weight to the traction slowly, gradually, and completely to help prevent and eliminate muscle spasms of the affected leg. The weight, hanging freely, usually creates enough pull on the muscle to release the spasm without increasing pain. Countertraction to the pelvis is contraindicated in Buck’s traction. Assessing the four Ps (pounds, pull, pulleys, and pressure) ensures that traction is applied correctly. Eliminating potential pressure points is important but not related to muscle spasms.

 

DIF:    Cognitive Level: Apply                   REF:   Page 463

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

3. A patient complains of a slight tingling in the toes of the affected leg 2 hours after the application of Buck’s traction with a foam boot with Velcro straps. Which nursing intervention will prevent potential complications related to the patient complaint?

a.	Apply warm blankets to the feet and reassess.
b.	Check the fit of the traction device near the knee.
c.	Medicate the patient for pain with an opioid analgesic.
d.	Reassure the patient that this is a common complaint.

 

 

ANS:  B

Tingling in tissue distal to a potential constriction indicates neurovascular impairment caused by nerve compression or irritation. The nurse should inspect the patient’s knee area because this area is most likely to be affected by pressure from the traction device. Nursing intervention can prevent a potential complication of neurovascular impairment such as nerve damage by detecting the source of the pressure and eliminating the pressure. Warm blankets might be applied to increase regional tissue warmth and comfort, but they do not address the possible constriction. Although effective for pain, opioid analgesic agents are ineffective therapy for tingling unless administered in excessive doses that alter the level of consciousness. Addressing the cause of the tingling is more important. It is inappropriate to assure the patient that the complaint is common since tingling is a sign of nerve compression and the compression needs to be alleviated.

 

DIF:    Cognitive Level: Apply                   REF:   Page 464

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment

 

4. The nurse assesses the traction boot for a proper fit. Which observation by the nurse verifies that the patient has a properly fitting Buck’s traction boot?

a.	The heel rests firmly on the inner heel padding of the boot.
b.	The leg slips out of the boot after applying weight.
c.	The pain level increases from a level of 6 to 7 on a scale of 10.
d.	The traction boot fits snugly without pressure points.

 

 

ANS:  D

The nurse observes a snug fit without prolonged exposure to pressure for leg protection against traction forces; the boot maintains adequate neurovascular function and provides effective traction to the affected region. The nurse should also observe a well-seated heel in the boot and baseline neurovascular assessment findings. Padding at the heel of a traction boot is contraindicated because the boot is manufactured to distribute pressure over the heel and leg. If the leg slips out of the boot when weight is applied, the boot is too loose. After application of the traction, pain should decrease.

 

DIF:    Cognitive Level: Comprehend          REF:   Page 462

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment