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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
: Engaging in open communication and active listening demonstrates effective nursing collaboration. Collaboration involves actively participating in discussions, sharing information, and valuing the input of all team members.
a. Refusing to seek input from other team members is not conducive to collaboration and can hinder the effectiveness of patient care.
c. Failing to communicate changes in the patient's condition can lead to errors and compromises patient safety, which is contrary to effective collaboration.
d. Limiting collaboration to only certain team members can create barriers and may result in missed opportunities for valuable input from different perspectives.
Correct Answer is C
Explanation
The patient being unable to move the affected limb in skin traction requires further assessment. Traction should allow some degree of movement, and the nurse should investigate the cause of the restricted motion and take appropriate action.
a. The patient being able to perform active range of motion exercises indicates that some mobility is possible with the traction, which is a positive finding.
b. The patient experiencing some discomfort during range of motion exercises is not unexpected, as traction may cause some discomfort due to realignment of the bone.
d. The patient having difficulty moving the affected limb may be expected with skin traction, and the nurse should continue to monitor the patient's progress.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.