The nurse is providing discharge education to a patient with skin traction. Which instruction should the nurse include?
"Avoid any weight-bearing activities for the duration of traction."
"You may remove the traction device at night for more comfort."
"Clean the skin under the traction tape with alcohol wipes daily."
"Report any signs of skin redness or irritation to your healthcare provider."
The Correct Answer is D
Option D is the correct instruction because the patient should be vigilant in monitoring for any signs of skin redness, irritation, or discomfort under the traction tape. Promptly reporting these symptoms to the healthcare provider allows for early intervention and prevention of skin complications.
a. "Avoid any weight-bearing activities for the duration of traction" is incorrect because weight-bearing activities are typically restricted only in certain types of traction, such as skeletal traction. The nurse should specify any activity restrictions based on the type of traction provided to the patient.
b. "You may remove the traction device at night for more comfort" is incorrect. Skin traction is a continuous intervention, and removing the device can compromise its effectiveness in providing traction and immobilizing the affected limb.
c. "Clean the skin under the traction tape with alcohol wipes daily" is incorrect. Alcohol wipes can cause skin dryness and irritation, which may exacerbate skin issues under the traction tape. The nurse should recommend gentle cleaning and moisturizing as needed.
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 C
Explanation
Weakness in the unaffected leg may indicate nerve compression or impairment, which requires further assessment and intervention to prevent neurovascular complications.
a. Symmetrical pedal pulses bilaterally indicate adequate circulation to both legs and are a positive finding.
b. Capillary refill time less than 2 seconds indicates good peripheral perfusion and is a normal finding.
d. Tingling sensation in the toes may be expected with skin traction, but it does not necessarily indicate a complication unless it is accompanied by other neurovascular changes.
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