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

Using friction when washing the affected area can irritate the skin and worsen acne. Gentle cleansing is recommended to avoid aggravating the condition.

Choice B rationale

Using a new cosmetic pad with each limited application of makeup helps prevent the spread of bacteria and reduces the risk of further clogging pores, which can exacerbate acne.

Choice C rationale

Using an oil-based soap can clog pores and worsen acne. Non-comedogenic, water-based cleansers are recommended for acne-prone skin.

Choice D rationale

Expressing larger comedones periodically can lead to skin damage and scarring. It is better to use appropriate acne treatments to manage comedones.

A. To limit the amount of bleeding and clots from the surgical site. B. To eliminate the need for wound irrigations. C. To prevent drainage from accumulating in the wound. D. To provide a means for medication administration.

Correct Answer is C

Explanation

Choice A rationale

While a JP drain can help limit bleeding and clots, its primary purpose is not to control bleeding. It is more focused on preventing fluid accumulation.

Choice B rationale

A JP drain does not eliminate the need for wound irrigations. Wound irrigations may still be necessary to clean the wound and prevent infection.

Choice C rationale

The primary purpose of a Jackson-Pratt (JP) drain is to prevent drainage from accumulating in the wound. By removing excess fluid, the JP drain helps reduce the risk of infection and promotes faster healing.

Choice D rationale

A JP drain is not used for medication administration. It is specifically designed to remove fluid from the surgical site.

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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 a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client?

Correct Answer is B

Explanation

A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?

Correct Answer is C

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?