The nurse is performing neurovascular checks on a patient with skin traction. Which assessment finding would be of concern and require immediate action?
Capillary refill of less than 3 seconds in the affected limb.
Warm and pink skin color in the affected limb.
Absent pedal pulses in the affected foot.
Mild tingling sensation in the affected limb.
The Correct Answer is C
Absent pedal pulses in the affected foot could indicate compromised circulation and require immediate action. The nurse should notify the healthcare provider promptly to assess and address the issue.
a. Capillary refill of less than 3 seconds in the affected limb is a normal finding and indicates adequate peripheral circulation.
b. Warm and pink skin color in the affected limb is a normal finding and indicates good blood flow.
d. Mild tingling sensation in the affected limb can be a common sensation due to traction, and it does not indicate neurovascular compromise.
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Correct Answer is C
Explanation
A. Applying petroleum jelly to the skin under the traction tape. Petroleum jelly should not be applied, as it can soften the skin and increase the risk of maceration or skin breakdown under the traction tape.
B. Keeping the traction device loose to allow for movement. The traction must remain properly secured to maintain alignment and prevent further injury. Loosening it defeats the purpose of traction and can lead to complications.
C. Repositioning the patient every 4 hours.Repositioning at least every 2- 4 hours helps relieve pressure, promote circulation, and prevent skin breakdown.Turning every 4 hours on a viscoelastic foam mattress/surface results in fewer pressure ulcers than turning every 2 hours on a standard mattress.
D. Applying direct pressure to the skin over bony prominences. Applying direct pressure to bony prominences increases the risk of skin breakdown and worsens pressure injuries. Instead, pressure should be relieved by using cushions or proper repositioning techniques.
Correct Answer is B
Explanation
Adjusting the weight used in skin traction without a healthcare provider's order can lead to complications or improper alignment of the fractured bone. Weight adjustments should only be made based on the healthcare provider's instructions.
a. Elevating the affected limb can help reduce edema but may not be specific to skin traction care.
c. Keeping the adhesive straps or wraps clean and dry is essential to prevent skin breakdown and infection, but it is not the primary nursing consideration related to traction.
d. Encouraging active range of motion exercises is not recommended while the patient is in skin traction, as it may disrupt the traction's stabilizing effect on the fractured bone. Passive range of motion exercises may be performed as appropriate, with the healthcare provider's approval.
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