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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Swelling and discoloration of the affected limb can indicate neurovascular compromise and require immediate intervention. The nurse should assess circulation, sensation, and motion of the affected limb and notify the healthcare provider promptly.
a. Mild discomfort at the traction site is common and expected. The nurse can provide pain relief measures as prescribed.
c. Traction weights hanging freely off the edge of the bed is the correct way to set up skin traction. This finding does not raise concern.
d. Traction cords secured with tape to the bedrails is the appropriate way to secure the traction. This finding does not raise concern.
Correct Answer is B
Explanation
: Engaging in open communication and active listening demonstrates effective nursing collaboration. Collaboration involves actively participating in discussions, sharing information, and valuing the input of all team members.
a. Refusing to seek input from other team members is not conducive to collaboration and can hinder the effectiveness of patient care.
c. Failing to communicate changes in the patient's condition can lead to errors and compromises patient safety, which is contrary to effective collaboration.
d. Limiting collaboration to only certain team members can create barriers and may result in missed opportunities for valuable input from different perspectives.
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