The nurse is assessing a patient with skin traction for any potential complications. Which finding requires immediate intervention?

Mild redness around the traction tape.

Slight discomfort at the traction site.

Skin irritation from the adhesive strips.

Purplish discoloration below the traction site.

Answer and Explanation

The Correct Answer is D

Purplish discoloration below the traction site may indicate impaired circulation, and it requires immediate intervention to prevent further complications like pressure ulcers or nerve damage.

a. Mild redness around the traction tape is common and may be expected, but it does not require immediate intervention unless it worsens or is accompanied by other signs of infection.

b. Slight discomfort at the traction site is expected as a result of the applied tension, and it can be managed with appropriate pain management techniques.

c. Skin irritation from the adhesive strips can be addressed by repositioning the strips or using appropriate skin protection measures.

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Correct Answer is D

Explanation

Requesting physical therapy to assist with range of motion exercises demonstrates effective nursing collaboration. Physical therapists are experts in movement and can provide valuable input in promoting joint mobility for patients in traction.

a. Administering pain medication as prescribed is a standard nursing responsibility and does not involve collaboration with other healthcare providers.

b. Initiating skin traction without consulting the healthcare provider is not appropriate. Traction requires a healthcare provider's order, and nurses should not initiate any treatment without proper authorization.

c. Documenting the patient's neurovascular assessment in the chart is a part of the nurse's routine responsibilities and does not involve collaboration with other healthcare providers.

A. Apply lotion to the skin under the traction tape. B. Check the skin under the traction tape daily for redness. C. Keep the traction device tightly secured at all times. D. Massage the skin under the traction tape to improve circulation.

Correct Answer is B

Explanation

Checking the skin under the traction tape daily for redness is essential to monitor for signs of skin breakdown. This allows the nurse to identify early signs of pressure and adjust the traction as needed to prevent skin complications.

a. Applying lotion to the skin under the traction tape is not recommended, as it can create a barrier and interfere with the traction's effectiveness. It may also contribute to skin breakdown.

c. Keeping the traction device tightly secured at all times can lead to excessive pressure on the skin and increase the risk of skin breakdown. The traction should be secured firmly but not excessively tight.

d. Massaging the skin under the traction tape is not advisable, as it can cause friction and further damage the skin, increasing the risk of skin breakdown.

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The nurse is assessing a patient with skin traction for any potential complications. Which finding requires immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient in skin traction. Which action demonstrates effective nursing collaboration?

Correct Answer is D

Explanation

The nurse is caring for a patient with a fractured femur who has been placed in skin traction. Which action should the nurse take to prevent skin breakdown?

Correct Answer is B

Explanation

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