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 D
Explanation
Deep tissue damage with visible blisters requires 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. Minor irritation from the traction device can be managed by ensuring proper padding and positioning of the device. It is not a critical concern unless it worsens or leads to more severe skin issues.
c. Mild itching around the traction area may be common, but the nurse should assess for any signs of infection or allergic reaction. Immediate intervention is not typically required for mild itching.
Correct Answer is B
Explanation
Skin traction is contraindicated in patients with open fractures where the skin is disrupted. The risk of infection and further complications is high in such cases.
a. Skin traction is not contraindicated in patients with a history of joint dislocations. It is primarily used for fractures.
c. Skin traction is not contraindicated in patients with muscle strains, as it is specific to fractures.
d. Skin traction is not contraindicated in patients with chronic orthopedic conditions; however, it may not be the appropriate intervention for their condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.