The nurse is assessing a patient with skin traction. What finding would be of concern and require immediate intervention?
Mild discomfort at the traction site.
Swelling and discoloration of the affected limb.
Traction weights hanging freely off the edge of the bed.
Traction cords secured with tape to the bedrails.
The Correct Answer is B
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.
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Related Questions
Correct Answer is C
Explanation
The patient being unable to move the affected limb in skin traction requires further assessment. Traction should allow some degree of movement, and the nurse should investigate the cause of the restricted motion and take appropriate action.
a. The patient being able to perform active range of motion exercises indicates that some mobility is possible with the traction, which is a positive finding.
b. The patient experiencing some discomfort during range of motion exercises is not unexpected, as traction may cause some discomfort due to realignment of the bone.
d. The patient having difficulty moving the affected limb may be expected with skin traction, and the nurse should continue to monitor the patient's progress.
Correct Answer is B
Explanation
Inadequate traction can lead to improper alignment, uneven pressure distribution, and increased risk of pressure ulcers. The nurse should ensure that the traction is appropriately applied to prevent complications.
a. Decreased muscle spasms may be a positive effect of adequate traction. However, inadequate traction does not necessarily lead to increased muscle spasms.
c. Improved circulation in the affected limb is a potential benefit of proper skin traction, not a complication of inadequate traction.
d. Faster healing of the injured limb is a desired outcome of effective traction. Inadequate traction may delay healing rather than promote it.
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