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.
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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
While mild discomfort may seem minor, it could indicate skin breakdown, pressure injury, or neurovascular compromise. The nurse must immediately assess circulation, sensation, and motion (CSM) in the affected limb to rule out complications such as compartment syndrome, nerve compression, or improper traction alignment.
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