The nurse is providing care to a patient in skin traction. Which intervention is essential to maintain proper traction and alignment?
Reapplying the traction tape every 4 hours.
Keeping the patient's leg in a dependent position.
Elevating the foot of the bed to promote venous return.
Ensuring the traction ropes are free of knots and kinks.
The Correct Answer is D
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is C
Explanation
To ensure proper alignment and prevent shearing forces on the skin, the nurse should use a lift sheet to slide the patient to the desired position. This reduces friction and minimizes the risk of skin breakdown.
a. Raising the head of the bed to a 30-degree angle does not address proper alignment for repositioning with skin traction.
b. Having the patient assist in turning to the side can place strain on the affected limb and is not recommended for patients with skin traction.
d. Applying a trochanter roll under the affected hip is not necessary for repositioning with skin traction.
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