The nurse is evaluating the skin condition of a patient in skeletal traction. Which finding requires immediate intervention?

Slight redness at the site of the traction tape.

Minor irritation from the traction device.

Mild itching around the traction area.

Deep tissue damage with visible blisters.

Answer and Explanation

The Correct Answer is D

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Asking the physical therapist for input on the patient's progress demonstrates effective nursing collaboration. The physical therapist's expertise is valuable in assessing the patient's response to range of motion exercises in traction.

a. Taking over the physical therapist's role in performing the exercises is not appropriate, as each healthcare professional has a specific scope of practice and should work collaboratively.

b. Informing the physical therapist that the exercises are unnecessary disregards the physical therapist's expertise and is not conducive to effective collaboration.

d. Disregarding the physical therapist's recommendations undermines the collaborative effort and diminishes the potential benefits of working together.

A. Raise the head of the bed to a 30-degree angle. B. Have the patient assist in turning to the side. C. Use a lift sheet to slide the patient to the desired position. D. Apply a trochanter roll under the affected hip.

Correct Answer is C

Explanation

To ensure proper alignment and prevent shearing forces on the skin, the nurse should use a lift sheet to slide the patient to the desired position. This reduces friction and minimizes the risk of skin breakdown.

a. Raising the head of the bed to a 30-degree angle does not address proper alignment for repositioning with skin traction.

b. Having the patient assist in turning to the side can place strain on the affected limb and is not recommended for patients with skin traction.

d. Applying a trochanter roll under the affected hip is not necessary for repositioning with skin traction.

View Question and Answer

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

The nurse is evaluating the skin condition of a patient in skeletal traction. Which finding requires immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is collaborating with the physical therapist to assist a patient in skin traction with range of motion exercises. Which action demonstrates effective nursing collaboration?

Correct Answer is C

Explanation

The nurse is preparing to reposition a patient with skin traction. What action should the nurse take to ensure proper alignment?

Correct Answer is C

Explanation

The nurse is assessing a patient with skin traction. Which finding requires immediate intervention?

The nurse is caring for a patient with a fractured femur in skin traction. Which action by the nurse is appropriate?

The nurse is caring for a patient with a fractured femur who has been placed in skin traction. Which action should the nurse take to prevent skin breakdown?

The nurse is preparing to apply skin traction for a patient with a fractured hip. Which area is the most appropriate location to apply the traction?

The nurse is collaborating with the healthcare team to provide care for a patient in skin traction. Which action demonstrates effective nursing collaboration?

Which of the following fractures would benefit from the use of skin traction?

How does skin traction compare to skeletal traction in nursing practice?

The nurse is assessing a patient in skin traction. Which finding indicates the need for immediate intervention?