The nurse is assessing a patient with skin traction. Which finding requires immediate intervention?
Slight redness at the site of the traction tape.
Mild discomfort during movement of the affected limb.
Pain rated as 6 out of 10 on the pain scale.
Visible signs of skin breakdown under the traction tape.
The Correct Answer is D
Visible signs of skin breakdown under the traction tape require 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. Mild discomfort during movement of the affected limb is common with skin traction, and the nurse should assess for any signs of worsening or intolerable pain.
c. Pain rated as 6 out of 10 on the pain scale should be addressed, but it does not require immediate intervention unless it is associated with other concerning signs or symptoms
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
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.
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