The nurse is evaluating the patient's pain level after applying skin traction. Which finding indicates the need for further intervention?
The patient rates pain as a 3 on a scale of 0 to 10.
The patient's pain is well-controlled with prescribed analgesics.
The patient reports occasional sharp pain during movement.
The patient states that the pain is worse with the traction off.
The Correct Answer is D
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Skin traction is contraindicated in patients with open fractures where the skin is disrupted. The risk of infection and further complications is high in such cases.
a. Skin traction is not contraindicated in patients with a history of joint dislocations. It is primarily used for fractures.
c. Skin traction is not contraindicated in patients with muscle strains, as it is specific to fractures.
d. Skin traction is not contraindicated in patients with chronic orthopedic conditions; however, it may not be the appropriate intervention for their condition.
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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