The nurse is evaluating the patient's range of motion in skin traction. Which finding requires further assessment?
The patient is able to perform active range of motion exercises.
The patient experiences some discomfort during range of motion.
The patient is unable to move the affected limb.
The patient has difficulty moving the affected limb.
The Correct Answer is C
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.
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Correct Answer is D
Explanation
In skin traction, adhesive straps or wraps are applied to the skin near the fractured area, and weights are attached to create a pulling force. The pulling force helps to align and stabilize the fractured bone.
a. Skin traction does not involve surgically inserting metal pins into the bone. That technique is called skeletal traction.
b. Skin traction does not apply pressure directly on the fracture site; it uses a pulling force applied through the skin.
c. Adhesive straps or wraps are applied near the fractured area, not directly over it, to avoid pressure on the fracture site.
Correct Answer is D
Explanation
Option D is the correct instruction because the patient should be vigilant in monitoring for any signs of skin redness, irritation, or discomfort under the traction tape. Promptly reporting these symptoms to the healthcare provider allows for early intervention and prevention of skin complications.
a. "Avoid any weight-bearing activities for the duration of traction" is incorrect because weight-bearing activities are typically restricted only in certain types of traction, such as skeletal traction. The nurse should specify any activity restrictions based on the type of traction provided to the patient.
b. "You may remove the traction device at night for more comfort" is incorrect. Skin traction is a continuous intervention, and removing the device can compromise its effectiveness in providing traction and immobilizing the affected limb.
c. "Clean the skin under the traction tape with alcohol wipes daily" is incorrect. Alcohol wipes can cause skin dryness and irritation, which may exacerbate skin issues under the traction tape. The nurse should recommend gentle cleaning and moisturizing as needed.
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