The nurse is assessing a patient with skin traction. What finding would be of concern and require immediate intervention?
Mild discomfort at the traction site.
Swelling and discoloration of the affected limb.
Traction weights hanging freely off the edge of the bed.
Traction cords secured with tape to the bedrails.
The Correct Answer is B
Swelling and discoloration of the affected limb can indicate neurovascular compromise and require immediate intervention. The nurse should assess circulation, sensation, and motion of the affected limb and notify the healthcare provider promptly.
a. Mild discomfort at the traction site is common and expected. The nurse can provide pain relief measures as prescribed.
c. Traction weights hanging freely off the edge of the bed is the correct way to set up skin traction. This finding does not raise concern.
d. Traction cords secured with tape to the bedrails is the appropriate way to secure the traction. This finding does not raise concern.
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Related Questions
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 D
Explanation
The patient stating that the pain is worse with the traction off requires further intervention. Skin traction should relieve pain and discomfort; an increase in pain when the traction is off may indicate inadequate traction or an underlying issue.
a. The patient rating pain as a 3 on a scale of 0 to 10 suggests mild pain and may be expected with some level of discomfort related to the fracture and traction.
b. The patient's pain being well-controlled with prescribed analgesics is a positive finding and indicates that the current pain management plan is effective.
c. The patient reporting occasional sharp pain during movement may be expected with skin traction, but the nurse should assess for any signs of worsening or intolerable pain.
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