The nurse is caring for a patient with skin traction. What is an important nursing intervention to prevent complications?
Elevate the foot of the bed for comfort.
Loosen the traction bandages every 8 hours.
Assess the patient's pain level once a day.
Monitor neurovascular status regularly.
The Correct Answer is D
An important nursing intervention to prevent complications in a patient with skin traction is to monitor neurovascular status regularly. This includes assessing circulation, sensation, and motion of the affected limb to detect any signs of neurovascular compromise.
a. Elevating the foot of the bed for comfort is not directly related to preventing complications of skin traction.
b. Loosening the traction bandages every 8 hours can compromise the effectiveness of the traction and is not a recommended nursing intervention.
c. Assessing the patient's pain level once a day is important, but it is not the primary intervention for preventing complications of skin traction.
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Correct Answer is B
Explanation
The correct action to prevent skin breakdown in a patient with skin traction is to ensure that the traction weight is hanging freely and not resting on the bed. This prevents pressure on the skin and reduces the risk of skin breakdown.
a. Applying lotion to the skin under the traction can create a barrier that may interfere with proper skin assessment and could cause skin irritation. It is not recommended to apply lotion under the traction.
c. Loosening the traction bandages every 2 hours can compromise the effectiveness of the traction and may not be necessary if the skin is not showing signs of compromise.
d. Removing the traction periodically to assess the skin can disrupt the treatment plan and may not be necessary unless there are signs of skin compromise or other complications.
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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