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 D
Explanation
In skin traction, adhesive straps or wraps are applied to the skin near the fractured area, and weights are attached to create a pulling force. The pulling force helps to align and stabilize the fractured bone.
a. Skin traction does not involve surgically inserting metal pins into the bone. That technique is called skeletal traction.
b. Skin traction does not apply pressure directly on the fracture site; it uses a pulling force applied through the skin.
c. Adhesive straps or wraps are applied near the fractured area, not directly over it, to avoid pressure on the fracture site.
Correct Answer is D
Explanation
An important nursing intervention to prevent complications in a patient with skin traction is to monitor neurovascular status regularly. This includes assessing circulation, sensation, and motion of the affected limb to detect any signs of neurovascular compromise.
a. Elevating the foot of the bed for comfort is not directly related to preventing complications of skin traction.
b. Loosening the traction bandages every 8 hours can compromise the effectiveness of the traction and is not a recommended nursing intervention.
c. Assessing the patient's pain level once a day is important, but it is not the primary intervention for preventing complications of skin traction.
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