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 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.
Correct Answer is B
Explanation
A potential complication of skin traction is pressure ulcer development due to constant pressure on the skin from the traction apparatus. The nurse should regularly assess the skin under the traction to prevent skin breakdown.
a. Increased risk of falls is not directly related to skin traction. However, the nurse should implement fall prevention measures for all patients as appropriate.
c. Hypertension is not directly related to skin traction. It is a condition characterized by elevated blood pressure.
d. Constipation is not directly related to skin traction. It can be caused by various factors, including medications and immobility, but it is not a specific complication of skin traction.
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