The nurse is caring for a patient with skin traction. What action should the nurse take to prevent skin breakdown?
Apply lotion to the skin under the traction.
Ensure that the traction weight is hanging freely.
Loosen the traction bandages every 2 hours.
Remove the traction periodically to assess the skin.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Checking for signs of skin breakdown or pressure sores is essential to prevent complications associated with skin traction. The patient should inspect the skin around the traction site regularly and report any abnormalities to the healthcare provider.
a. Removing the traction weights without healthcare provider approval can lead to inadequate traction and compromise its effectiveness.
b. Avoiding movements that cause tension on the traction is essential to maintain proper alignment and prevent further injury.
c. Reapplying the traction tape daily is not necessary and may lead to skin irritation. Proper application by healthcare professionals is essential to maintain the appropriate tension.
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