The nurse is caring for a patient with skin traction. What is an important nursing intervention to prevent complications?
Elevate the foot of the bed for comfort.
Loosen the traction bandages every 8 hours.
Assess the patient's pain level once a day.
Monitor neurovascular status regularly.
The Correct Answer is D
An important nursing intervention to prevent complications in a patient with skin traction is to monitor neurovascular status regularly. This includes assessing circulation, sensation, and motion of the affected limb to detect any signs of neurovascular compromise.
a. Elevating the foot of the bed for comfort is not directly related to preventing complications of skin traction.
b. Loosening the traction bandages every 8 hours can compromise the effectiveness of the traction and is not a recommended nursing intervention.
c. Assessing the patient's pain level once a day is important, but it is not the primary intervention for preventing complications of skin traction.
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Correct Answer is C
Explanation
The primary purpose of applying skin traction is to provide a pulling force on the fractured bone, which helps to reduce and realign the bone fragments. It allows for proper bone healing and minimizes pain and muscle spasms.
a. Skin traction does not completely immobilize the fractured bone; it provides some mobility while stabilizing the fracture.
b. Realignment of the fractured bone into its original position is the goal of closed reduction or surgical intervention, not skin traction.
d. While skin traction may promote some blood circulation in the affected limb, its primary purpose is to reduce the fracture and stabilize the bone, not to improve circulation.
Correct Answer is D
Explanation
Visible signs of skin breakdown under the traction tape require immediate intervention. It indicates that the skin is compromised, and the patient is at risk of developing pressure ulcers or skin breakdown. Prompt action is necessary to prevent further damage and ensure patient safety.
a. Slight redness at the site of the traction tape may be expected, and the nurse should monitor for any signs of worsening or discomfort. It does not require immediate intervention unless it progresses.
b. Mild discomfort during movement of the affected limb is common with skin traction, and the nurse should assess for any signs of worsening or intolerable pain.
c. Pain rated as 6 out of 10 on the pain scale should be addressed, but it does not require immediate intervention unless it is associated with other concerning signs or symptoms
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