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 C
Explanation
Weakness in the unaffected leg may indicate nerve compression or impairment, which requires further assessment and intervention to prevent neurovascular complications.
a. Symmetrical pedal pulses bilaterally indicate adequate circulation to both legs and are a positive finding.
b. Capillary refill time less than 2 seconds indicates good peripheral perfusion and is a normal finding.
d. Tingling sensation in the toes may be expected with skin traction, but it does not necessarily indicate a complication unless it is accompanied by other neurovascular changes.
Correct Answer is C
Explanation
Using a clear and concise verbal report is an effective approach to nursing communication. It allows for the efficient transfer of essential patient information to the healthcare provider.
a. Sending a text message to the healthcare provider may not be appropriate for discussing patient information as it may not be secure and may lack important details.
b. Speaking in medical jargon during the conversation can lead to miscommunication and misunderstandings between the nurse and the healthcare provider.
d. Providing the healthcare provider with outdated patient data is not effective in patient care and may lead to incorrect decision-making.
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