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 C
Explanation
The primary purpose of applying skin traction is to provide a pulling force on the fractured bone, which helps to reduce and realign the bone fragments. It allows for proper bone healing and minimizes pain and muscle spasms.
a. Skin traction does not completely immobilize the fractured bone; it provides some mobility while stabilizing the fracture.
b. Realignment of the fractured bone into its original position is the goal of closed reduction or surgical intervention, not skin traction.
d. While skin traction may promote some blood circulation in the affected limb, its primary purpose is to reduce the fracture and stabilize the bone, not to improve circulation.
Correct Answer is C
Explanation
Skin traction is a type of traction that involves applying force to the skin to reduce swelling and edema around the fractured bone. It helps to alleviate pain and promote proper alignment of the bone fragments.
a. Skin traction does not immobilize the fractured bone; rather, it provides continuous but controlled tension to reduce swelling and discomfort.
b. Skin traction is not applied directly to the fractured bone. Instead, it involves applying adhesive strips or bandages to the skin, followed by connecting weights to provide the desired tension.
d. While skin traction may promote some mobility, its primary purpose is to reduce swelling and discomfort rather than facilitating early ambulation.
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