The nurse is caring for a patient in skin traction. Which action demonstrates effective nursing collaboration?
Administering pain medication as prescribed.
Initiating skin traction without consulting the healthcare provider.
Documenting the patient's neurovascular assessment in the chart.
Requesting physical therapy to assist with range of motion exercises.
The Correct Answer is D
Requesting physical therapy to assist with range of motion exercises demonstrates effective nursing collaboration. Physical therapists are experts in movement and can provide valuable input in promoting joint mobility for patients in traction.
a. Administering pain medication as prescribed is a standard nursing responsibility and does not involve collaboration with other healthcare providers.
b. Initiating skin traction without consulting the healthcare provider is not appropriate. Traction requires a healthcare provider's order, and nurses should not initiate any treatment without proper authorization.
c. Documenting the patient's neurovascular assessment in the chart is a part of the nurse's routine responsibilities and does not involve collaboration with other healthcare providers.
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Correct Answer is A
Explanation
The patient's report of minimal discomfort indicates successful skin traction. Traction should alleviate pain and provide proper alignment of the fractured bone, leading to improved comfort for the patient.
b. The patient's pain being unchanged from before traction suggests that the traction may not be effectively relieving the pressure on the fractured bone.
c. The patient's leg appearing slightly misaligned indicates that the traction may not be adequately stabilizing the fracture, which is not a desirable outcome.
d. The patient's fractured femur showing signs of healing is not an immediate evaluation parameter for skin traction effectiveness. Skin traction is primarily aimed at reducing pain and realigning the bone.
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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