The nurse is performing neurovascular checks on a patient with skin traction. Which assessment finding would be of concern and require immediate action?
Capillary refill of less than 3 seconds in the affected limb.
Warm and pink skin color in the affected limb.
Absent pedal pulses in the affected foot.
Mild tingling sensation in the affected limb.
The Correct Answer is C
Absent pedal pulses in the affected foot could indicate compromised circulation and require immediate action. The nurse should notify the healthcare provider promptly to assess and address the issue.
a. Capillary refill of less than 3 seconds in the affected limb is a normal finding and indicates adequate peripheral circulation.
b. Warm and pink skin color in the affected limb is a normal finding and indicates good blood flow.
d. Mild tingling sensation in the affected limb can be a common sensation due to traction, and it does not indicate neurovascular compromise.
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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
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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