The nurse is caring for a patient in skin traction and is monitoring the patient's neurovascular status. Which finding indicates a potential complication?
Symmetrical pedal pulses bilaterally.
Capillary refill time less than 2 seconds.
Weakness in the unaffected leg.
Tingling sensation in the toes.
The Correct Answer is C
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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Related Questions
Correct Answer is B
Explanation
Weak pedal pulses in the affected leg indicate a potential vascular compromise and are concerning in a patient with skin traction. It may indicate reduced blood flow, and immediate intervention is required to ensure proper circulation to the extremity.
a. Capillary refill time of less than 2 seconds is a normal finding and indicates adequate peripheral circulation. It is not indicative of a complication.
c. Symmetrical pedal pulses bilaterally are a positive finding and suggest good vascular status in both legs. It is not a potential complication.
d. Tingling sensation in the toes may be a normal sensation and does not necessarily indicate a complication unless it is accompanied by other neurovascular changes.
Correct Answer is D
Explanation
Checking for signs of skin breakdown or pressure sores is essential to prevent complications associated with skin traction. The patient should inspect the skin around the traction site regularly and report any abnormalities to the healthcare provider.
a. Removing the traction weights without healthcare provider approval can lead to inadequate traction and compromise its effectiveness.
b. Avoiding movements that cause tension on the traction is essential to maintain proper alignment and prevent further injury.
c. Reapplying the traction tape daily is not necessary and may lead to skin irritation. Proper application by healthcare professionals is essential to maintain the appropriate tension.
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