Medical-surgical II

A nurse begins a shift caring for a patient who has been in skeletal traction for several days and works through the whole apparatus and the patient. Which findings require nursing action or a report? Select all that apply.

• AOne of the ropes has begun to fray where it passes over a pulley wheel
• BThe skin around one of the sites where the hardware enters the bone is reddened, tender, and has a small amount of new drainage
• CA weight is resting on the floor when the head of the bed is raised for meals
• DThe patient's unaffected leg is being moved through its range several times a day
• EThe patient reports that the traction is uncomfortable at the point where the hardware passes through the bone