The nurse is evaluating the patient's neurovascular status in skin traction. Which finding indicates a potential complication?
Capillary refill time of less than 2 seconds.
Weak pedal pulses in the affected leg.
Symmetrical pedal pulses bilaterally.
Tingling sensation in the toes.
The Correct Answer is B
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.
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Related Questions
Correct Answer is C
Explanation
The patient should not remove the traction device independently. Removing the traction can compromise the effectiveness of fracture reduction and delay healing. Only healthcare professionals should adjust or remove the traction as needed.
a. Cleaning the skin under the traction tape with mild soap and water daily helps to maintain skin integrity and reduce the risk of infection.
b. Reporting any signs of skin redness or irritation to the nurse is essential to monitor for potential skin breakdown and prevent complications.
d. Using the trapeze bar to reposition in bed is an appropriate method for the patient to move independently without compromising the traction's stability.
Correct Answer is B
Explanation
Adjusting the weight used in skin traction without a healthcare provider's order can lead to complications or improper alignment of the fractured bone. Weight adjustments should only be made based on the healthcare provider's instructions.
a. Elevating the affected limb can help reduce edema but may not be specific to skin traction care.
c. Keeping the adhesive straps or wraps clean and dry is essential to prevent skin breakdown and infection, but it is not the primary nursing consideration related to traction.
d. Encouraging active range of motion exercises is not recommended while the patient is in skin traction, as it may disrupt the traction's stabilizing effect on the fractured bone. Passive range of motion exercises may be performed as appropriate, with the healthcare provider's approval.
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