Musculoskeletal System > Medical Surgical
Exam Review
Skin Traction
Total Questions : 48
Showing 48 questions, Sign in for moreWhich statement best describes skin traction in nursing practice?
Explanation
Skin traction is a technique commonly used in orthopedic nursing to stabilize and align fractured bones without the need for invasive surgery. It involves attaching adhesive straps or wraps to the skin around the fractured area and applying a pulling force to maintain proper alignment.
a. Skin traction does not involve the application of a cast. It is a temporary and non-invasive method used to stabilize a fracture before further treatment is provided.
b. Skin traction is not used to reduce dislocated joints. It is specifically used for fractures.
d. Skin traction is not a surgical procedure but rather a non-surgical intervention used in conjunction with other treatments.
What is the primary goal of using skin traction for a patient with a fractured bone?
Explanation
The primary goal of using skin traction is to provide pain relief and reduce discomfort in patients with fractured bones. Traction helps to stabilize the fracture and alleviate pressure on the affected area, leading to pain relief.
a. While some immobilization is achieved with skin traction, the main focus is on pain relief and not complete immobilization.
c. Early ambulation is not the primary goal of skin traction. Ambulation is usually initiated once the fracture is stabilized and appropriate treatment is provided.
d. While skin traction may indirectly support bone healing by reducing pain and allowing proper alignment, it is not the primary goal of this intervention.
Which statement accurately explains how skin traction is applied?
Explanation
In skin traction, adhesive straps or wraps are applied to the skin near the fractured area, and weights are attached to create a pulling force. The pulling force helps to align and stabilize the fractured bone.
a. Skin traction does not involve surgically inserting metal pins into the bone. That technique is called skeletal traction.
b. Skin traction does not apply pressure directly on the fracture site; it uses a pulling force applied through the skin.
c. Adhesive straps or wraps are applied near the fractured area, not directly over it, to avoid pressure on the fracture site.
What is an important nursing consideration when caring for a patient with skin traction?
Explanation
Adjusting the weight used in skin traction without a healthcare provider's order can lead to complications or improper alignment of the fractured bone. Weight adjustments should only be made based on the healthcare provider's instructions.
a. Elevating the affected limb can help reduce edema but may not be specific to skin traction care.
c. Keeping the adhesive straps or wraps clean and dry is essential to prevent skin breakdown and infection, but it is not the primary nursing consideration related to traction.
d. Encouraging active range of motion exercises is not recommended while the patient is in skin traction, as it may disrupt the traction's stabilizing effect on the fractured bone. Passive range of motion exercises may be performed as appropriate, with the healthcare provider's approval.
Which statement is true regarding the use of skin traction?
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.
What is the primary indication for using skin traction in nursing practice?
Explanation
The primary indication for skin traction is to provide short-term stabilization and pain relief for a fractured bone. It is a non-invasive method used to align and stabilize fractures before definitive treatment, such as casting or surgery.
a. Skin traction is not used to treat chronic orthopedic conditions; it is primarily used for acute fractures.
b. Skin traction is not typically used to immobilize a fractured bone during surgery; other surgical interventions are used for that purpose.
d. Skin traction does not replace the need for surgical interventions for joint dislocations; it is specifically used for fractures.
Which patient would benefit most from the use of skin traction?
Explanation
Skin traction is most beneficial for patients with fractures who are awaiting definitive treatment, such as surgical fixation. It provides temporary stabilization and pain relief for the fractured bone until further treatment is initiated.
a. Skin traction is not typically used for chronic joint inflammation; it is specific to fractures.
b. Skin traction is not used to treat dislocated joints; other interventions are employed for joint reductions.
d. Skin traction is not indicated for muscle strains; it is primarily used for fractures.
When is skin traction contraindicated in patient care?
Explanation
Skin traction is contraindicated in patients with open fractures where the skin is disrupted. The risk of infection and further complications is high in such cases.
a. Skin traction is not contraindicated in patients with a history of joint dislocations. It is primarily used for fractures.
c. Skin traction is not contraindicated in patients with muscle strains, as it is specific to fractures.
d. Skin traction is not contraindicated in patients with chronic orthopedic conditions; however, it may not be the appropriate intervention for their condition.
Which of the following fractures would benefit from the use of skin traction?
Explanation
Skin traction can be used for certain types of fractures, including hairline fractures, to provide temporary stabilization and pain relief.
b. Compound fractures involve broken bones that pierce the skin, which is a contraindication for skin traction.
c. Stress fractures are overuse injuries and may not require skin traction for management.
d. Greenstick fractures are incomplete fractures common in children, and their management may not necessitate skin traction.
How does skin traction compare to skeletal traction in nursing practice?
Explanation
Skin traction and skeletal traction are both used to stabilize and immobilize fractured bones, but they differ in the method of application. Skin traction uses weights attached to adhesive straps on the skin near the fractured area, while skeletal traction involves weights connected to metal pins inserted directly into the bone.
a. Skin traction is less invasive than skeletal traction because it does not require surgical insertion of metal pins.
c. Skin traction is not only used for chronic orthopedic conditions; it is commonly used for acute fractures as well.
d. Skin traction is not used to replace surgical interventions; it is an adjunctive intervention used in conjunction with other treatments for fractures.
Which type of skin traction is commonly used for patients with hip fractures?
Explanation
Buck's traction is commonly used for patients with hip fractures. It involves the application of skin traction to the lower extremity to stabilize the hip joint and provide pain relief before surgery.
b. Russell's traction is used for patients with lower leg fractures to reduce muscle spasms and align the bones. It is not the most common type of traction used for hip fractures.
c. Bryant's traction is specifically designed for pediatric patients with femur fractures. It is not typically used for hip fractures in adult patients.
d. Dunlop's traction is a type of head and neck traction used for cervical spine injuries. It is not used for hip fractures.
Which type of skin traction is often used for patients with lower leg fractures?
Explanation
Russell's traction is used for patients with lower leg fractures to reduce muscle spasms and align the bones. It involves the application of skin traction to the lower leg.
a. Buck's traction is commonly used for patients with hip fractures, not lower leg fractures.
c. Bryant's traction is specifically designed for pediatric patients with femur fractures, not lower leg fractures in adult patients.
d. Dunlop's traction is a type of head and neck traction used for cervical spine injuries, not lower leg fractures.
Which type of skin traction is specifically designed for pediatric patients with femur fractures?
Explanation
Bryant's traction is specifically designed for pediatric patients with femur fractures. It involves elevating the legs and applying skin traction to the lower extremities to stabilize the fracture.
a. Buck's traction is commonly used for patients with hip fractures, not pediatric patients with femur fractures.
b. Russell's traction is used for patients with lower leg fractures, not pediatric femur fractures.
d. Dunlop's traction is a type of head and neck traction used for cervical spine injuries, not pediatric femur fractures.
Which type of skin traction is applied to patients with fractures of the lower back and lower extremities?
Explanation
Buck's traction is often used for patients with fractures of the lower back and lower extremities. It helps stabilize the area and reduce pain before further treatment.
b. Russell's traction is used for lower leg fractures, not fractures of the lower back and lower extremities.
c. Bryant's traction is specifically designed for pediatric femur fractures, not fractures in the lower back or lower extremities.
d. Dunlop's traction is a type of head and neck traction, not used for fractures of the lower back or lower extremities.
The nurse is caring for a patient with skin traction. What action should the nurse take to prevent skin breakdown?
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.
The nurse is assessing a patient with skin traction. What finding would be of concern and require immediate intervention?
Explanation
Swelling and discoloration of the affected limb can indicate neurovascular compromise and require immediate intervention. The nurse should assess circulation, sensation, and motion of the affected limb and notify the healthcare provider promptly.
a. Mild discomfort at the traction site is common and expected. The nurse can provide pain relief measures as prescribed.
c. Traction weights hanging freely off the edge of the bed is the correct way to set up skin traction. This finding does not raise concern.
d. Traction cords secured with tape to the bedrails is the appropriate way to secure the traction. This finding does not raise concern.
The nurse is preparing to reposition a patient with skin traction. What action should the nurse take to ensure proper alignment?
Explanation
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.
The nurse is performing neurovascular checks on a patient with skin traction. Which assessment finding would be of concern and require immediate action?
Explanation
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.
The nurse is providing discharge teaching to a patient with skin traction. What instruction should the nurse include to promote skin integrity?
Explanation
To promote skin integrity, the nurse should instruct the patient to inspect the skin under the traction daily for signs of redness, irritation, or breakdown. Early detection of skin issues can help prevent further complications.
a. Applying lotion to the skin under the traction is not recommended, as it can interfere with proper skin assessment and cause skin irritation.
b. Cleaning the skin under the traction with alcohol swabs daily can dry out the skin and increase the risk of skin breakdown.
c. Using a barrier cream on the skin under the traction is not necessary and may not be suitable for all patients. It can also interfere with skin assessment.
The nurse is caring for a patient with skin traction. What is a potential complication of skin traction?
Explanation
A potential complication of skin traction is pressure ulcer development due to constant pressure on the skin from the traction apparatus. The nurse should regularly assess the skin under the traction to prevent skin breakdown.
a. Increased risk of falls is not directly related to skin traction. However, the nurse should implement fall prevention measures for all patients as appropriate.
c. Hypertension is not directly related to skin traction. It is a condition characterized by elevated blood pressure.
d. Constipation is not directly related to skin traction. It can be caused by various factors, including medications and immobility, but it is not a specific complication of skin traction.
The nurse is providing care for a patient in skin traction. What intervention should the nurse implement to prevent contractures?
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.
The nurse is caring for a patient with skin traction. What is a potential complication of inadequate traction?
Explanation
Inadequate traction can lead to improper alignment, uneven pressure distribution, and increased risk of pressure ulcers. The nurse should ensure that the traction is appropriately applied to prevent complications.
a. Decreased muscle spasms may be a positive effect of adequate traction. However, inadequate traction does not necessarily lead to increased muscle spasms.
c. Improved circulation in the affected limb is a potential benefit of proper skin traction, not a complication of inadequate traction.
d. Faster healing of the injured limb is a desired outcome of effective traction. Inadequate traction may delay healing rather than promote it.
The nurse is caring for a patient with skin traction. What is an important nursing intervention to prevent complications?
Explanation
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.
The nurse is caring for a patient in skin traction. What is a potential complication of skin traction if not properly secured?
Explanation
If the skin traction is not properly secured, there is a risk of traction weight displacement, leading to improper alignment and ineffective traction. Proper securing of the traction is essential to maintain its therapeutic effect.
a. Fracture of the affected limb is not a direct complication of improperly secured skin traction. Fractures are typically treated with other methods, such as casting or surgical interventions.
b. Infection at the traction site may occur if proper hygiene and wound care practices are not followed. It is not directly related to the security of the traction.
d. Excessive traction pressure can occur if the traction is not properly applied or adjusted. However, the primary concern is traction weight displacement, which affects the effectiveness of the treatment.
The nurse is caring for a patient in skin traction. Which action demonstrates effective nursing collaboration?
Explanation
Requesting physical therapy to assist with range of motion exercises demonstrates effective nursing collaboration. Physical therapists are experts in movement and can provide valuable input in promoting joint mobility for patients in traction.
a. Administering pain medication as prescribed is a standard nursing responsibility and does not involve collaboration with other healthcare providers.
b. Initiating skin traction without consulting the healthcare provider is not appropriate. Traction requires a healthcare provider's order, and nurses should not initiate any treatment without proper authorization.
c. Documenting the patient's neurovascular assessment in the chart is a part of the nurse's routine responsibilities and does not involve collaboration with other healthcare providers.
The nurse is caring for a patient in skin traction. When communicating with the healthcare provider about the patient's condition, which approach demonstrates effective nursing communication?
Explanation
Using a clear and concise verbal report is an effective approach to nursing communication. It allows for the efficient transfer of essential patient information to the healthcare provider.
a. Sending a text message to the healthcare provider may not be appropriate for discussing patient information as it may not be secure and may lack important details.
b. Speaking in medical jargon during the conversation can lead to miscommunication and misunderstandings between the nurse and the healthcare provider.
d. Providing the healthcare provider with outdated patient data is not effective in patient care and may lead to incorrect decision-making.
The nurse is collaborating with the physical therapist to assist a patient in skin traction with range of motion exercises. Which action demonstrates effective nursing collaboration?
Explanation
Asking the physical therapist for input on the patient's progress demonstrates effective nursing collaboration. The physical therapist's expertise is valuable in assessing the patient's response to range of motion exercises in traction.
a. Taking over the physical therapist's role in performing the exercises is not appropriate, as each healthcare professional has a specific scope of practice and should work collaboratively.
b. Informing the physical therapist that the exercises are unnecessary disregards the physical therapist's expertise and is not conducive to effective collaboration.
d. Disregarding the physical therapist's recommendations undermines the collaborative effort and diminishes the potential benefits of working together.
The nurse is collaborating with the healthcare team to provide care for a patient in skin traction. Which action demonstrates effective nursing collaboration?
Explanation
: Engaging in open communication and active listening demonstrates effective nursing collaboration. Collaboration involves actively participating in discussions, sharing information, and valuing the input of all team members.
a. Refusing to seek input from other team members is not conducive to collaboration and can hinder the effectiveness of patient care.
c. Failing to communicate changes in the patient's condition can lead to errors and compromises patient safety, which is contrary to effective collaboration.
d. Limiting collaboration to only certain team members can create barriers and may result in missed opportunities for valuable input from different perspectives.
The nurse is collaborating with the physical therapist to coordinate care for a patient in skin traction. Which action demonstrates effective nursing collaboration?
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.
The nurse is evaluating the effectiveness of skin traction for a patient with a fractured femur. Which finding indicates successful traction?
Explanation
The patient's report of minimal discomfort indicates successful skin traction. Traction should alleviate pain and provide proper alignment of the fractured bone, leading to improved comfort for the patient.
b. The patient's pain being unchanged from before traction suggests that the traction may not be effectively relieving the pressure on the fractured bone.
c. The patient's leg appearing slightly misaligned indicates that the traction may not be adequately stabilizing the fracture, which is not a desirable outcome.
d. The patient's fractured femur showing signs of healing is not an immediate evaluation parameter for skin traction effectiveness. Skin traction is primarily aimed at reducing pain and realigning the bone.
The nurse is evaluating the skin condition of a patient in skeletal traction. Which finding requires immediate intervention?
Explanation
Deep tissue damage with visible blisters requires immediate intervention. It indicates that the skin is compromised, and the patient is at risk of developing pressure ulcers or skin breakdown. Prompt action is necessary to prevent further damage and ensure patient safety.
a. Slight redness at the site of the traction tape may be expected, and the nurse should monitor for any signs of worsening or discomfort. It does not require immediate intervention unless it progresses.
b. Minor irritation from the traction device can be managed by ensuring proper padding and positioning of the device. It is not a critical concern unless it worsens or leads to more severe skin issues.
c. Mild itching around the traction area may be common, but the nurse should assess for any signs of infection or allergic reaction. Immediate intervention is not typically required for mild itching.
The nurse is evaluating the patient's neurovascular status in skin traction. Which finding indicates a potential complication?
Explanation
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.
The nurse is evaluating the patient's pain level after applying skin traction. Which finding indicates the need for further intervention?
Explanation
The patient stating that the pain is worse with the traction off requires further intervention. Skin traction should relieve pain and discomfort; an increase in pain when the traction is off may indicate inadequate traction or an underlying issue.
a. The patient rating pain as a 3 on a scale of 0 to 10 suggests mild pain and may be expected with some level of discomfort related to the fracture and traction.
b. The patient's pain being well-controlled with prescribed analgesics is a positive finding and indicates that the current pain management plan is effective.
c. The patient reporting occasional sharp pain during movement may be expected with skin traction, but the nurse should assess for any signs of worsening or intolerable pain.
The nurse is evaluating the patient's range of motion in skin traction. Which finding requires further assessment?
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.
The nurse is caring for a patient with a fractured femur in skin traction. Which action by the nurse is appropriate?
Explanation
Option A is appropriate because assessing the skin under the traction tape helps monitor for any signs of skin breakdown, irritation, or pressure ulcers. Regular skin assessments are essential to prevent complications related to skin traction.
b. Tightening the traction ropes to increase the traction force is incorrect. The traction force should be set by the healthcare provider, and altering it without proper authorization may lead to adverse effects or further injury.
c. Placing the traction weights on the bed instead of suspending them is incorrect. Traction weights should be suspended freely to provide the appropriate traction force and maintain proper alignment of the fractured bone.
The nurse is providing discharge education to a patient with skin traction. Which instruction should the nurse include?
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.
The nurse is assessing a patient in skin traction. Which finding indicates the need for immediate intervention?
Explanation
Option D indicates the need for immediate intervention. Warm toes and a capillary refill time of less than 2 seconds suggest potential vascular compromise, and the nurse should assess for any signs of reduced circulation and promptly notify the healthcare provider.
a. The patient's skin under the traction tape being pink and intact is a positive finding and suggests proper skin integrity. No immediate intervention is needed.
b. The patient reporting mild discomfort at the traction site is not uncommon, and the nurse should assess for any signs of worsening or intolerable pain. It does not require immediate intervention.
c. The traction weight being correctly calibrated and suspended freely is a correct practice and does not indicate a need for immediate intervention.
The nurse is providing care to a patient in skin traction. Which intervention is essential to maintain proper traction and alignment?
Explanation
Option D is essential in maintaining proper traction and alignment. Knots and kinks in the traction ropes can interfere with the traction force, leading to inadequate realignment of the fractured bone.
a. Reapplying the traction tape every 4 hours is not necessary and may cause skin irritation and complications. Traction tape is typically applied securely and remains in place for an extended period unless specifically indicated otherwise.
b. Keeping the patient's leg in a dependent position is incorrect. The affected leg should be elevated to reduce swelling and promote venous return to prevent further complications such as venous thromboembolism.
c. Elevating the foot of the bed to promote venous return is not a recommended practice for skin traction. The affected limb should be elevated to promote venous return, but the bed should remain flat to maintain the proper alignment and traction force.
The nurse is caring for a patient with a fractured femur who has been placed in skin traction. Which statement best describes the purpose of skin traction?
Explanation
Skin traction is a type of traction that involves applying force to the skin to reduce swelling and edema around the fractured bone. It helps to alleviate pain and promote proper alignment of the bone fragments.
a. Skin traction does not immobilize the fractured bone; rather, it provides continuous but controlled tension to reduce swelling and discomfort.
b. Skin traction is not applied directly to the fractured bone. Instead, it involves applying adhesive strips or bandages to the skin, followed by connecting weights to provide the desired tension.
d. While skin traction may promote some mobility, its primary purpose is to reduce swelling and discomfort rather than facilitating early ambulation.
The nurse is preparing to apply skin traction for a patient with a fractured hip. Which area is the most appropriate location to apply the traction?
Explanation
Skin traction is typically applied above the fractured area to provide a pulling force in the opposite direction to reduce swelling and discomfort. The traction should not be placed directly over the fractured bone to avoid further injury.
a. Placing traction directly over the fractured bone may exacerbate the fracture and cause additional harm.
b. Applying traction to the unaffected leg is not appropriate, as it will not address the fractured hip.
c. Applying traction to the bony prominence on the affected side can cause pressure sores and skin breakdown.
The nurse is assessing a patient with skin traction for any potential complications. Which finding requires immediate intervention?
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.
The nurse is caring for a patient in skin traction and is monitoring the patient's neurovascular status. Which finding indicates a potential complication?
Explanation
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.
The nurse is educating a patient with skin traction about self-care measures. Which instruction should the nurse provide to the patient?
Explanation
Checking for signs of skin breakdown or pressure sores is essential to prevent complications associated with skin traction. The patient should inspect the skin around the traction site regularly and report any abnormalities to the healthcare provider.
a. Removing the traction weights without healthcare provider approval can lead to inadequate traction and compromise its effectiveness.
b. Avoiding movements that cause tension on the traction is essential to maintain proper alignment and prevent further injury.
c. Reapplying the traction tape daily is not necessary and may lead to skin irritation. Proper application by healthcare professionals is essential to maintain the appropriate tension.
The nurse is caring for a patient with a fractured femur who has been placed in skin traction. Which action should the nurse take to prevent skin breakdown?
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.
The nurse is preparing to apply skin traction to a patient's lower leg. What is the primary purpose of applying skin traction in this situation?
Explanation
The primary purpose of applying skin traction is to provide a pulling force on the fractured bone, which helps to reduce and realign the bone fragments. It allows for proper bone healing and minimizes pain and muscle spasms.
a. Skin traction does not completely immobilize the fractured bone; it provides some mobility while stabilizing the fracture.
b. Realignment of the fractured bone into its original position is the goal of closed reduction or surgical intervention, not skin traction.
d. While skin traction may promote some blood circulation in the affected limb, its primary purpose is to reduce the fracture and stabilize the bone, not to improve circulation.
The nurse is caring for a patient in skin traction. Which intervention is essential to prevent pressure ulcers?
Explanation
Repositioning the patient every 4 hours is essential to prevent pressure ulcers. Skin traction can place pressure on specific areas of the skin, and repositioning helps to distribute pressure evenly, reducing the risk of pressure ulcers.
a. Applying petroleum jelly to the skin under the traction tape is not recomm
ended, as it can create a barrier and interfere with the traction's effectiveness. It may also contribute to skin breakdown. b. Keeping the traction device loose to allow for movement can lead to inadequate traction and ineffective fracture reduction. The traction should be appropriately secured.
d. Applying direct pressure to the skin over bony prominences can cause pressure ulcers, especially in patients in traction. It is not a recommended intervention.
The nurse is providing discharge instructions to a patient with skin traction. Which statement by the patient indicates a need for further teaching?
Explanation
The patient should not remove the traction device independently. Removing the traction can compromise the effectiveness of fracture reduction and delay healing. Only healthcare professionals should adjust or remove the traction as needed.
a. Cleaning the skin under the traction tape with mild soap and water daily helps to maintain skin integrity and reduce the risk of infection.
b. Reporting any signs of skin redness or irritation to the nurse is essential to monitor for potential skin breakdown and prevent complications.
d. Using the trapeze bar to reposition in bed is an appropriate method for the patient to move independently without compromising the traction's stability.
The nurse is assessing a patient with skin traction. Which finding requires immediate intervention?
Explanation
Visible signs of skin breakdown under the traction tape require immediate intervention. It indicates that the skin is compromised, and the patient is at risk of developing pressure ulcers or skin breakdown. Prompt action is necessary to prevent further damage and ensure patient safety.
a. Slight redness at the site of the traction tape may be expected, and the nurse should monitor for any signs of worsening or discomfort. It does not require immediate intervention unless it progresses.
b. Mild discomfort during movement of the affected limb is common with skin traction, and the nurse should assess for any signs of worsening or intolerable pain.
c. Pain rated as 6 out of 10 on the pain scale should be addressed, but it does not require immediate intervention unless it is associated with other concerning signs or symptoms
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