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
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 C
Explanation
The primary indication for skin traction is to provide short-term stabilization and pain relief for a fractured bone. It is a non-invasive method used to align and stabilize fractures before definitive treatment, such as casting or surgery.
a. Skin traction is not used to treat chronic orthopedic conditions; it is primarily used for acute fractures.
b. Skin traction is not typically used to immobilize a fractured bone during surgery; other surgical interventions are used for that purpose.
d. Skin traction does not replace the need for surgical interventions for joint dislocations; it is specifically used for fractures.
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