The nurse is evaluating the patient's neurovascular status in skin traction. Which finding indicates a potential complication?
Capillary refill time of less than 2 seconds.
Weak pedal pulses in the affected leg.
Symmetrical pedal pulses bilaterally.
Tingling sensation in the toes.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Purplish discoloration below the traction site may indicate impaired circulation, and it requires immediate intervention to prevent further complications like pressure ulcers or nerve damage.
a. Mild redness around the traction tape is common and may be expected, but it does not require immediate intervention unless it worsens or is accompanied by other signs of infection.
b. Slight discomfort at the traction site is expected as a result of the applied tension, and it can be managed with appropriate pain management techniques.
c. Skin irritation from the adhesive strips can be addressed by repositioning the strips or using appropriate skin protection measures.
Correct Answer is D
Explanation
Skin traction is a temporary and short-term intervention used to stabilize a fractured bone and provide pain relief before more definitive treatments, such as casting or surgery, are implemented.
a. Skin traction is not a long-term treatment and is usually used as an interim measure while more definitive treatments are planned.
b. Skin traction is not intended to replace surgical interventions but rather to provide stabilization until surgery is performed, if necessary.
c. Skin traction can be used before surgery but is not typically applied only during surgery for immediate fracture stabilization.
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