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 B
Explanation
The primary goal of using skin traction is to provide pain relief and reduce discomfort in patients with fractured bones. Traction helps to stabilize the fracture and alleviate pressure on the affected area, leading to pain relief.
a. While some immobilization is achieved with skin traction, the main focus is on pain relief and not complete immobilization.
c. Early ambulation is not the primary goal of skin traction. Ambulation is usually initiated once the fracture is stabilized and appropriate treatment is provided.
d. While skin traction may indirectly support bone healing by reducing pain and allowing proper alignment, it is not the primary goal of this intervention.
Correct Answer is C
Explanation
The patient should not remove the traction device independently. Removing the traction can compromise the effectiveness of fracture reduction and delay healing. Only healthcare professionals should adjust or remove the traction as needed.
a. Cleaning the skin under the traction tape with mild soap and water daily helps to maintain skin integrity and reduce the risk of infection.
b. Reporting any signs of skin redness or irritation to the nurse is essential to monitor for potential skin breakdown and prevent complications.
d. Using the trapeze bar to reposition in bed is an appropriate method for the patient to move independently without compromising the traction's stability.
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