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
The patient being unable to move the affected limb in skin traction requires further assessment. Traction should allow some degree of movement, and the nurse should investigate the cause of the restricted motion and take appropriate action.
a. The patient being able to perform active range of motion exercises indicates that some mobility is possible with the traction, which is a positive finding.
b. The patient experiencing some discomfort during range of motion exercises is not unexpected, as traction may cause some discomfort due to realignment of the bone.
d. The patient having difficulty moving the affected limb may be expected with skin traction, and the nurse should continue to monitor the patient's progress.
Correct Answer is C
Explanation
The primary purpose of applying skin traction is to provide a pulling force on the fractured bone, which helps to reduce and realign the bone fragments. It allows for proper bone healing and minimizes pain and muscle spasms.
a. Skin traction does not completely immobilize the fractured bone; it provides some mobility while stabilizing the fracture.
b. Realignment of the fractured bone into its original position is the goal of closed reduction or surgical intervention, not skin traction.
d. While skin traction may promote some blood circulation in the affected limb, its primary purpose is to reduce the fracture and stabilize the bone, not to improve circulation.
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