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?
Mild erythema
Serosanguineous drainage
Fever
Warmth
The Correct Answer is C
A. Mild erythema (redness) at the pin sites can be a normal finding due to the body's response to the presence of foreign objects. It may not necessarily indicate infection.
B. Serosanguineous drainage (a mixture of clear and bloody fluid) can also be a normal finding initially after the insertion of pins. It may not necessarily indicate infection.
C. Fever is a systemic response to infection. In a client with skeletal traction, fever can be an indication of an infection at the pin sites or a more systemic infection related to the traction device.
D. Warmth around the pin sites can be a normal finding due to the inflammatory response that occurs after pin insertion. It may not necessarily indicate infection.
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Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. Place a compression bandage on the ankle.
- This helps reduce swelling and provides support to the injured area.
B. Apply heat to the ankle
- This action is not recommended for acute sprains as it can increase swelling. Cold packs or ice should be used initially to reduce inflammation.
C. Encourage rest.
- Rest is important to allow the ankle to heal properly and prevent further injury.
D. Elevate the ankle.
- Elevating the ankle helps reduce swelling by allowing fluid to drain away from the injured area.
E. Perform passive range-of-motion exercises to the ankle.
- Gentle range-of-motion exercises can help prevent stiffness in the ankle joint. However, it's important to perform these exercises within the limits of comfort and not force any movements.
Correct Answer is B
Explanation
A. Inserting sterile packing into the nares is not indicated in this situation. Clear fluid drainage from the nose may be cerebrospinal fluid (CSF), and packing could cause further complications.
B. Allowing the drainage to drip onto a sterile gauze pad is the appropriate initial action. Clear fluid drainage from the nose after a traumatic event may be CSF, which can indicate a skull fracture and damage to the meninges. Collecting the fluid on a sterile gauze pad can help confirm the presence of CSF.
C. Suctioning the nose with a bulb syringe is not recommended because it can introduce contaminants into the nasal passages and potentially worsen the injury.
D. Obtaining a culture of the specimen using sterile swabs is a consideration once the presence of CSF is confirmed. However, the initial priority is to identify and collect the clear fluid drainage.
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