NCLEX Practice Test

Which intervention should be included in planning care for a client with a fractured femur in balanced suspension skeletal traction? Select all that apply.

1. Encourage intake of at least 2 L of clear fluids per day to prevent constipation

2. Ensure that the weights hang freely and do not touch the ground

3. Monitor for erythema, drainage, swelling, and malodor at the pin insertion sites

4. Perform frequent neurovascular checks on the affected extremity for the first 24 hours

5. Remove the weights for 10 minutes every 2 hours to prevent muscle spasm

The correct answer is: Encourage intake of at least 2 L of clear fluids per day to prevent constipation

The correct answer focuses on interventions that are essential for a client in balanced suspension skeletal traction for a fractured femur. Encouraging an intake of at least 2 liters of clear fluids per day is vital for several reasons. First, sufficient fluid intake helps to prevent constipation, which is a common concern in clients who are immobile or on bed rest due to their injury. Maintaining hydration can also improve overall health, support bowel function, and assist in the healing process by ensuring adequate circulation and nutrient delivery to tissues. In the context of balanced suspension skeletal traction, it's also important to consider issues surrounding safety and comfort. Ensuring that weights hang freely and do not touch the ground is crucial to maintain the effectiveness of the traction and prevent potential complications, such as disruption or inefficient traction. Additionally, monitoring for erythema, drainage, swelling, and malodor at the pin insertion sites is key to identifying signs of infection early. Performing frequent neurovascular checks on the affected extremity for the first 24 hours helps assess circulation and nerve function, further ensuring that any complications can be addressed promptly. Thus, while maintaining hydration is critical for managing the client's overall health, especially in preventing constipation, the other interventions are also necessary components to ensure that the client