A nurse is assessing a client who is in skeletal traction.
Which of the following findings should the nurse identify as an indication of infection at the pin sites?

Serosanguineous drainage.

Mild erythema.

Warmth.

Fever.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Serosanguineous drainage is a normal finding at pin sites and does not indicate infection. It is a mixture of serum and blood and is expected during the initial healing phase.

Choice B rationale

Mild erythema around the pin sites can be a normal inflammatory response and does not necessarily indicate infection. It is important to monitor for other signs of infection.

Choice C rationale

Warmth at the pin sites can be a normal finding due to increased blood flow during the healing process. However, it should be monitored in conjunction with other signs of infection.

Choice D rationale

Fever is a systemic sign of infection and indicates that the body is responding to an infectious process. It is a critical finding that requires prompt attention and intervention.

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Correct Answer is D

Explanation

Choice A rationale

The ropes being in the center of the wheel grooves is correct and ensures proper traction.

Choice B rationale

The ropes being securely attached to the pins is correct and necessary for effective traction.

Choice C rationale

The weights being equal on each side is correct and ensures balanced traction.

Choice D rationale

The weights resting against the foot of the bed is incorrect and can interfere with the effectiveness of the traction. .

A. Increased appetite. B. Nausea. C. Increased energy level. D. Seeing halos around bright objects. E. Photophobia.

Correct Answer is ["B","D","E"]

Explanation

Choice B rationale

Nausea is a common symptom of digoxin toxicity. Elevated levels of digoxin can lead to gastrointestinal disturbances, including nausea, vomiting, and loss of appetite.

Choice D rationale

Seeing halos around bright objects is a classic sign of digoxin toxicity. This visual disturbance, along with blurred vision and yellow-green vision, indicates that the digoxin level is too high.

Choice E rationale

Photophobia, or sensitivity to light, can also be a symptom of digoxin toxicity. This occurs due to the effects of digoxin on the visual system.

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A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?

Correct Answer is D

Explanation

The nurse is caring for a client prescribed digoxin to help manage heart failure. Which manifestations correlate with a digoxin level of 2.3 ng/dL? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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A nurse is assessing a client who is in skeletal traction.
Which of the following findings should the nurse identify as an indication of infection at the pin sites?