The nurse is assessing a patient in skin traction. Which finding indicates the need for immediate intervention?
The patient's skin under the traction tape is pink and intact.
The patient reports mild discomfort at the traction site.
The traction weight is correctly calibrated and suspended freely.
The patient's toes are warm, and capillary refill time is less than 2 seconds.
The Correct Answer is B
While mild discomfort may seem minor, it could indicate skin breakdown, pressure injury, or neurovascular compromise. The nurse must immediately assess circulation, sensation, and motion (CSM) in the affected limb to rule out complications such as compartment syndrome, nerve compression, or improper traction alignment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Skin traction and skeletal traction are both used to stabilize and immobilize fractured bones, but they differ in the method of application. Skin traction uses weights attached to adhesive straps on the skin near the fractured area, while skeletal traction involves weights connected to metal pins inserted directly into the bone.
a. Skin traction is less invasive than skeletal traction because it does not require surgical insertion of metal pins.
c. Skin traction is not only used for chronic orthopedic conditions; it is commonly used for acute fractures as well.
d. Skin traction is not used to replace surgical interventions; it is an adjunctive intervention used in conjunction with other treatments for fractures.
Correct Answer is D
Explanation
Option D is the correct instruction because the patient should be vigilant in monitoring for any signs of skin redness, irritation, or discomfort under the traction tape. Promptly reporting these symptoms to the healthcare provider allows for early intervention and prevention of skin complications.
a. "Avoid any weight-bearing activities for the duration of traction" is incorrect because weight-bearing activities are typically restricted only in certain types of traction, such as skeletal traction. The nurse should specify any activity restrictions based on the type of traction provided to the patient.
b. "You may remove the traction device at night for more comfort" is incorrect. Skin traction is a continuous intervention, and removing the device can compromise its effectiveness in providing traction and immobilizing the affected limb.
c. "Clean the skin under the traction tape with alcohol wipes daily" is incorrect. Alcohol wipes can cause skin dryness and irritation, which may exacerbate skin issues under the traction tape. The nurse should recommend gentle cleaning and moisturizing as needed.
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