*NURSING > ATI MEDICAL SURGICAL > ATI Medical Surgical Nursing, Care of Patients with Musculoskeletal Trauma (All)
ATI Medical Surgical Nursing, Care of Patients with Musculoskeletal Trauma
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A client has a fracture and is being treated with skeletal traction. Which assessment causes the nurse to take immediate action? a. The client’s blood pressure is 130/86 mm Hg. b. The traction... weights are resting on the floor. c. Slight oozing of clear fluid is noted at the pin site. d. Capillary refill of the extremity is less than 3 seconds. ANS: B The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. Slight oozing of clear fluid is normal as is the capillary refill time. The client’s blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Assessment) [Show More]
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