NCLEX Practice Test

Which of the following interventions should be included 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 key to understanding the care of a client with a fractured femur in balanced suspension skeletal traction lies in the importance of maintaining proper hydration and monitoring the physical status of the skeletal traction setup. Encouraging the intake of at least 2 liters of clear fluids per day is crucial because adequate hydration helps prevent constipation, a common issue in patients with limited mobility. Fluid intake ensures that bowel function remains normal, which is particularly important when patients are on medications or have decreased activity levels due to their injuries. Ensuring that the weights hang freely and do not touch the ground is fundamental for maintaining the effectiveness of the traction system. Allowing the weights to rest on the ground can disrupt the alignment and traction that are necessary for healing. This principle supports the overall goal of skeletal traction, which is to provide a steady, continuous pull to keep the fractured bone in the correct position. Monitoring for erythema, drainage, swelling, and malodor at the pin insertion sites is essential for preventing and identifying potential infection early. Infections can complicate healing and may lead to serious complications, so vigilant observation is part of responsible patient care in a traction setup. Performing frequent neurovascular checks on the affected extremity for the first 24 hours is critical to assess