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 A
Explanation
Encouraging active range of motion exercises can help prevent contractures by promoting joint mobility and muscle flexibility. Contractures can occur if the patient remains immobile for an extended period.
b. Applying ice packs to the affected limb is not directly related to preventing contractures. Ice packs are typically used to reduce inflammation and swelling.
c. Limiting the patient's fluid intake is not necessary for preventing contractures. Adequate hydration is essential for overall health and well-being.
d. Maintaining the traction in a continuous position is a standard practice for skin traction. However, it does not specifically address the prevention of contractures.
Correct Answer is D
Explanation
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.
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