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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["72"]
Explanation
Step 1 is to calculate the burned area using the Rule of Nines. The Rule of Nines assigns percentages to different body areas to estimate the total body surface area (TBSA) affected by burns. For example, each arm is 9%, each leg is 18%, the front and back of the torso are each 18%, and the head is 9%.
Step 1: Calculate the burned area. If the client has burns on the front and back of both legs, the calculation would be: (18% + 18%) + (18% + 18%) = 72%
The final calculated answer is 72%.
Correct Answer is C
Explanation
Choice A rationale
Red skin with edema in the nail beds is more indicative of a superficial injury or inflammation, such as cellulitis or a mild burn, rather than frostbite.
Choice B rationale
Black fingertips surrounded by an erythematous rash suggest gangrene or severe necrosis, which can occur in advanced stages of frostbite but is not an initial finding.
Choice C rationale
A white appearance to the skin that is insensitive to touch is a classic sign of frostbite. The lack of sensation is due to the freezing of tissues and nerves, and the white color indicates a lack of blood flow to the affected area.
Choice D rationale
A pink edematous hand is more indicative of a mild inflammatory response or early stages of frostbite before the tissue has frozen. It does not represent the more severe presentation of frostbite.
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