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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Related Questions
Correct Answer is D
Explanation
In skin traction, adhesive straps or wraps are applied to the skin near the fractured area, and weights are attached to create a pulling force. The pulling force helps to align and stabilize the fractured bone.
a. Skin traction does not involve surgically inserting metal pins into the bone. That technique is called skeletal traction.
b. Skin traction does not apply pressure directly on the fracture site; it uses a pulling force applied through the skin.
c. Adhesive straps or wraps are applied near the fractured area, not directly over it, to avoid pressure on the fracture site.
Correct Answer is C
Explanation
A. Applying petroleum jelly to the skin under the traction tape. Petroleum jelly should not be applied, as it can soften the skin and increase the risk of maceration or skin breakdown under the traction tape.
B. Keeping the traction device loose to allow for movement. The traction must remain properly secured to maintain alignment and prevent further injury. Loosening it defeats the purpose of traction and can lead to complications.
C. Repositioning the patient every 4 hours.Repositioning at least every 2- 4 hours helps relieve pressure, promote circulation, and prevent skin breakdown.Turning every 4 hours on a viscoelastic foam mattress/surface results in fewer pressure ulcers than turning every 2 hours on a standard mattress.
D. Applying direct pressure to the skin over bony prominences. Applying direct pressure to bony prominences increases the risk of skin breakdown and worsens pressure injuries. Instead, pressure should be relieved by using cushions or proper repositioning techniques.
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