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
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.
Correct Answer is C
Explanation
Skin traction is most beneficial for patients with fractures who are awaiting definitive treatment, such as surgical fixation. It provides temporary stabilization and pain relief for the fractured bone until further treatment is initiated.
a. Skin traction is not typically used for chronic joint inflammation; it is specific to fractures.
b. Skin traction is not used to treat dislocated joints; other interventions are employed for joint reductions.
d. Skin traction is not indicated for muscle strains; it is primarily used for fractures.
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