The nurse is assessing a patient with skin traction. Which finding requires immediate intervention?
Slight redness at the site of the traction tape.
Mild discomfort during movement of the affected limb.
Pain rated as 6 out of 10 on the pain scale.
Visible signs of skin breakdown under the traction tape.
The Correct Answer is D
Visible signs of skin breakdown under the traction tape require immediate intervention. It indicates that the skin is compromised, and the patient is at risk of developing pressure ulcers or skin breakdown. Prompt action is necessary to prevent further damage and ensure patient safety.
a. Slight redness at the site of the traction tape may be expected, and the nurse should monitor for any signs of worsening or discomfort. It does not require immediate intervention unless it progresses.
b. Mild discomfort during movement of the affected limb is common with skin traction, and the nurse should assess for any signs of worsening or intolerable pain.
c. Pain rated as 6 out of 10 on the pain scale should be addressed, but it does not require immediate intervention unless it is associated with other concerning signs or symptoms
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Related Questions
Correct Answer is D
Explanation
Option D is essential in maintaining proper traction and alignment. Knots and kinks in the traction ropes can interfere with the traction force, leading to inadequate realignment of the fractured bone.
a. Reapplying the traction tape every 4 hours is not necessary and may cause skin irritation and complications. Traction tape is typically applied securely and remains in place for an extended period unless specifically indicated otherwise.
b. Keeping the patient's leg in a dependent position is incorrect. The affected leg should be elevated to reduce swelling and promote venous return to prevent further complications such as venous thromboembolism.
c. Elevating the foot of the bed to promote venous return is not a recommended practice for skin traction. The affected limb should be elevated to promote venous return, but the bed should remain flat to maintain the proper alignment and traction force.
Correct Answer is D
Explanation
Option D is the correct instruction because the patient should be vigilant in monitoring for any signs of skin redness, irritation, or discomfort under the traction tape. Promptly reporting these symptoms to the healthcare provider allows for early intervention and prevention of skin complications.
a. "Avoid any weight-bearing activities for the duration of traction" is incorrect because weight-bearing activities are typically restricted only in certain types of traction, such as skeletal traction. The nurse should specify any activity restrictions based on the type of traction provided to the patient.
b. "You may remove the traction device at night for more comfort" is incorrect. Skin traction is a continuous intervention, and removing the device can compromise its effectiveness in providing traction and immobilizing the affected limb.
c. "Clean the skin under the traction tape with alcohol wipes daily" is incorrect. Alcohol wipes can cause skin dryness and irritation, which may exacerbate skin issues under the traction tape. The nurse should recommend gentle cleaning and moisturizing as needed.
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