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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Deep tissue damage with visible blisters requires 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. Minor irritation from the traction device can be managed by ensuring proper padding and positioning of the device. It is not a critical concern unless it worsens or leads to more severe skin issues.
c. Mild itching around the traction area may be common, but the nurse should assess for any signs of infection or allergic reaction. Immediate intervention is not typically required for mild itching.
Correct Answer is D
Explanation
Purplish discoloration below the traction site may indicate impaired circulation, and it requires immediate intervention to prevent further complications like pressure ulcers or nerve damage.
a. Mild redness around the traction tape is common and may be expected, but it does not require immediate intervention unless it worsens or is accompanied by other signs of infection.
b. Slight discomfort at the traction site is expected as a result of the applied tension, and it can be managed with appropriate pain management techniques.
c. Skin irritation from the adhesive strips can be addressed by repositioning the strips or using appropriate skin protection measures.
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