The nurse is educating a patient with skin traction about self-care measures. Which instruction should the nurse provide to the patient?
"You can remove the traction weights if you feel uncomfortable."
"Avoid any movements that cause tension on the traction."
"Reapply the traction tape daily to ensure a tight fit."
"Check for any signs of skin breakdown or pressure sores."
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
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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