The nurse is preparing to reposition a patient with skin traction. What action should the nurse take to ensure proper alignment?
Raise the head of the bed to a 30-degree angle.
Have the patient assist in turning to the side.
Use a lift sheet to slide the patient to the desired position.
Apply a trochanter roll under the affected hip.
The Correct Answer is C
To ensure proper alignment and prevent shearing forces on the skin, the nurse should use a lift sheet to slide the patient to the desired position. This reduces friction and minimizes the risk of skin breakdown.
a. Raising the head of the bed to a 30-degree angle does not address proper alignment for repositioning with skin traction.
b. Having the patient assist in turning to the side can place strain on the affected limb and is not recommended for patients with skin traction.
d. Applying a trochanter roll under the affected hip is not necessary for repositioning with skin traction.
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Correct Answer is D
Explanation
Engaging in regular communication to discuss the patient's progress demonstrates effective nursing collaboration. This allows the nurse and physical therapist to coordinate care, make adjustments to the treatment plan, and ensure the best possible outcomes for the patient.
a. Taking over the physical therapist's treatment plan without discussion is not collaborative and can lead to misunderstandings and conflicts between the nurse and the physical therapist.
b. Providing the physical therapist with outdated patient information can compromise the patient's care and is not conducive to effective collaboration.
c. Scheduling therapy sessions at a convenient time for the nurse disregards the needs and progress of the patient, which is not a collaborative approach.
Correct Answer is C
Explanation
The patient being unable to move the affected limb in skin traction requires further assessment. Traction should allow some degree of movement, and the nurse should investigate the cause of the restricted motion and take appropriate action.
a. The patient being able to perform active range of motion exercises indicates that some mobility is possible with the traction, which is a positive finding.
b. The patient experiencing some discomfort during range of motion exercises is not unexpected, as traction may cause some discomfort due to realignment of the bone.
d. The patient having difficulty moving the affected limb may be expected with skin traction, and the nurse should continue to monitor the patient's progress.
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