The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client?
ExplanationSkin traction is achieved by Ace wraps, boots, or slings that apply a direct force on the client’s skin. Traction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as a result of immobility and monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.
