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 B

Explanation

Choice A rationale

While pain management is important, maintaining the airway is the priority intervention for a client with deep partial- and full-thickness burns to the face, chest, abdomen, and upper arms. Burns to the face and chest can cause airway edema and compromise breathing.

Choice B rationale

Maintaining the airway is the priority intervention during the resuscitation phase of injury for a client with burns to the face, chest, abdomen, and upper arms. Airway edema can develop rapidly, and securing the airway is crucial to ensure adequate oxygenation and ventilation.

Choice C rationale

Inserting an indwelling urinary catheter is important for monitoring urine output and fluid balance, but it is not the priority intervention. Airway management takes precedence in this scenario.

Choice D rationale

Initiating fluid resuscitation is essential for managing burn shock and maintaining hemodynamic stability, but maintaining the airway is the priority intervention to ensure the client can breathe adequately.

A. A client whose daily caloric intake is 25% fat. B. A client who has diabetes mellitus. C. A client who consumes two 12-ounce (0.35-L) alcoholic beverages daily. D. A client who has hypothyroidism.

Correct Answer is B

Explanation

Choice A rationale

A daily caloric intake of 25% fat is within the recommended range and does not significantly increase the risk for peripheral arterial disease (PAD).

Choice B rationale

Diabetes mellitus is a significant risk factor for PAD. High blood sugar levels can damage blood vessels and lead to poor circulation.

Choice C rationale

Consuming two 12-ounce alcoholic beverages daily can contribute to other health issues but is not a primary risk factor for PAD.

Choice D rationale

Hypothyroidism is not directly linked to an increased risk of PAD. It can cause other cardiovascular issues but not specifically PAD.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?

Correct Answer is B

Explanation

A nurse is providing teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?

Correct Answer is B

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?