The nurse is caring for a patient in skin traction and is monitoring the patient's neurovascular status. Which finding indicates a potential complication?
Symmetrical pedal pulses bilaterally.
Capillary refill time less than 2 seconds.
Weakness in the unaffected leg.
Tingling sensation in the toes.
The Correct Answer is C
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Engaging in regular communication to discuss the patient's progress demonstrates effective nursing collaboration. This allows the nurse and physical therapist to coordinate care, make adjustments to the treatment plan, and ensure the best possible outcomes for the patient.
a. Taking over the physical therapist's treatment plan without discussion is not collaborative and can lead to misunderstandings and conflicts between the nurse and the physical therapist.
b. Providing the physical therapist with outdated patient information can compromise the patient's care and is not conducive to effective collaboration.
c. Scheduling therapy sessions at a convenient time for the nurse disregards the needs and progress of the patient, which is not a collaborative approach.
Correct Answer is B
Explanation
The correct action to prevent skin breakdown in a patient with skin traction is to ensure that the traction weight is hanging freely and not resting on the bed. This prevents pressure on the skin and reduces the risk of skin breakdown.
a. Applying lotion to the skin under the traction can create a barrier that may interfere with proper skin assessment and could cause skin irritation. It is not recommended to apply lotion under the traction.
c. Loosening the traction bandages every 2 hours can compromise the effectiveness of the traction and may not be necessary if the skin is not showing signs of compromise.
d. Removing the traction periodically to assess the skin can disrupt the treatment plan and may not be necessary unless there are signs of skin compromise or other complications.
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