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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
To promote skin integrity, the nurse should instruct the patient to inspect the skin under the traction daily for signs of redness, irritation, or breakdown. Early detection of skin issues can help prevent further complications.
a. Applying lotion to the skin under the traction is not recommended, as it can interfere with proper skin assessment and cause skin irritation.
b. Cleaning the skin under the traction with alcohol swabs daily can dry out the skin and increase the risk of skin breakdown.
c. Using a barrier cream on the skin under the traction is not necessary and may not be suitable for all patients. It can also interfere with skin assessment.
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