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
Skin traction is typically applied above the fractured area to provide a pulling force in the opposite direction to reduce swelling and discomfort. The traction should not be placed directly over the fractured bone to avoid further injury.
a. Placing traction directly over the fractured bone may exacerbate the fracture and cause additional harm.
b. Applying traction to the unaffected leg is not appropriate, as it will not address the fractured hip.
c. Applying traction to the bony prominence on the affected side can cause pressure sores and skin breakdown.
Correct Answer is A
Explanation
The patient's report of minimal discomfort indicates successful skin traction. Traction should alleviate pain and provide proper alignment of the fractured bone, leading to improved comfort for the patient.
b. The patient's pain being unchanged from before traction suggests that the traction may not be effectively relieving the pressure on the fractured bone.
c. The patient's leg appearing slightly misaligned indicates that the traction may not be adequately stabilizing the fracture, which is not a desirable outcome.
d. The patient's fractured femur showing signs of healing is not an immediate evaluation parameter for skin traction effectiveness. Skin traction is primarily aimed at reducing pain and realigning the bone.
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