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.
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 B
Explanation
A potential complication of skin traction is pressure ulcer development due to constant pressure on the skin from the traction apparatus. The nurse should regularly assess the skin under the traction to prevent skin breakdown.
a. Increased risk of falls is not directly related to skin traction. However, the nurse should implement fall prevention measures for all patients as appropriate.
c. Hypertension is not directly related to skin traction. It is a condition characterized by elevated blood pressure.
d. Constipation is not directly related to skin traction. It can be caused by various factors, including medications and immobility, but it is not a specific complication of skin traction.
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