The nurse is caring for a patient in skin traction. Which intervention is essential to prevent pressure ulcers?
Applying petroleum jelly to the skin under the traction tape.
Keeping the traction device loose to allow for movement.
Repositioning the patient every 4 hours.
Applying direct pressure to the skin over bony prominences.
The Correct Answer is C
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The patient stating that the pain is worse with the traction off requires further intervention. Skin traction should relieve pain and discomfort; an increase in pain when the traction is off may indicate inadequate traction or an underlying issue.
a. The patient rating pain as a 3 on a scale of 0 to 10 suggests mild pain and may be expected with some level of discomfort related to the fracture and traction.
b. The patient's pain being well-controlled with prescribed analgesics is a positive finding and indicates that the current pain management plan is effective.
c. The patient reporting occasional sharp pain during movement may be expected with skin traction, but the nurse should assess for any signs of worsening or intolerable pain.
Correct Answer is B
Explanation
Weak pedal pulses in the affected leg indicate a potential vascular compromise and are concerning in a patient with skin traction. It may indicate reduced blood flow, and immediate intervention is required to ensure proper circulation to the extremity.
a. Capillary refill time of less than 2 seconds is a normal finding and indicates adequate peripheral circulation. It is not indicative of a complication.
c. Symmetrical pedal pulses bilaterally are a positive finding and suggest good vascular status in both legs. It is not a potential complication.
d. Tingling sensation in the toes may be a normal sensation and does not necessarily indicate a complication unless it is accompanied by other neurovascular changes.
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