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 ["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.
Correct Answer is D
Explanation
Choice D rationale
Positioning the client on the abdomen for 20 to 30 minutes twice a day helps prevent hip flexion contractures. This position stretches the hip flexor muscles, reducing the risk of contractures and promoting better range of motion.
Choice A rationale
Maintaining the client in a supine position does not effectively prevent hip flexion contractures. It is important to vary the client’s position to avoid stiffness and promote mobility.
Choice B rationale
Maintaining a high-Fowler’s position when the client is in bed can increase the risk of hip flexion contractures. This position keeps the hip flexed, which can lead to contractures over time.
Choice C rationale
Elevating the stump on a pillow can help reduce swelling but does not address the prevention of hip flexion contractures. The focus should be on positioning that stretches the hip flexors.
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