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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Absent pedal pulses in the affected foot could indicate compromised circulation and require immediate action. The nurse should notify the healthcare provider promptly to assess and address the issue.
a. Capillary refill of less than 3 seconds in the affected limb is a normal finding and indicates adequate peripheral circulation.
b. Warm and pink skin color in the affected limb is a normal finding and indicates good blood flow.
d. Mild tingling sensation in the affected limb can be a common sensation due to traction, and it does not indicate neurovascular compromise.
Correct Answer is A
Explanation
Skin traction can be used for certain types of fractures, including hairline fractures, to provide temporary stabilization and pain relief.
b. Compound fractures involve broken bones that pierce the skin, which is a contraindication for skin traction.
c. Stress fractures are overuse injuries and may not require skin traction for management.
d. Greenstick fractures are incomplete fractures common in children, and their management may not necessitate skin traction.
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