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
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 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.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.