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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Option D is essential in maintaining proper traction and alignment. Knots and kinks in the traction ropes can interfere with the traction force, leading to inadequate realignment of the fractured bone.
a. Reapplying the traction tape every 4 hours is not necessary and may cause skin irritation and complications. Traction tape is typically applied securely and remains in place for an extended period unless specifically indicated otherwise.
b. Keeping the patient's leg in a dependent position is incorrect. The affected leg should be elevated to reduce swelling and promote venous return to prevent further complications such as venous thromboembolism.
c. Elevating the foot of the bed to promote venous return is not a recommended practice for skin traction. The affected limb should be elevated to promote venous return, but the bed should remain flat to maintain the proper alignment and traction force.
Correct Answer is B
Explanation
Inadequate traction can lead to improper alignment, uneven pressure distribution, and increased risk of pressure ulcers. The nurse should ensure that the traction is appropriately applied to prevent complications.
a. Decreased muscle spasms may be a positive effect of adequate traction. However, inadequate traction does not necessarily lead to increased muscle spasms.
c. Improved circulation in the affected limb is a potential benefit of proper skin traction, not a complication of inadequate traction.
d. Faster healing of the injured limb is a desired outcome of effective traction. Inadequate traction may delay healing rather than promote it.
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