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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Holding the wrist at a 90-degree flexion is known as Phalen's maneuver, which is a test for carpal tunnel syndrome. This position puts pressure on the median nerve, potentially reproducing the client's symptoms.
B. Flexing the right arm at the elbow is not a specific test for carpal tunnel syndrome.
C. Holding the right arm straight is not a specific test for carpal tunnel syndrome.
D. Extending the right arm upward is not a specific test for carpal tunnel syndrome.
Correct Answer is B
Explanation
A. Remain on bedrest for the first 24 hr.: This is not recommended after arthroscopic knee surgery. Early mobilization and ambulation are encouraged to prevent complications such as blood clots and promote healing.
B. Apply ice to the affected area: This is an important instruction. Applying ice can help reduce swelling and pain after surgery. It's typically recommended for the first 24-48 hours.
C. Begin active range of motion: While range of motion exercises are important, they should be initiated as directed by the healthcare provider, and they should be done gently to avoid straining the surgical site.
D. Keep the leg in a dependent position: This is not recommended. Elevating the leg can help reduce swelling and promote circulation. Keeping the leg in a dependent position could exacerbate swelling and discomfort.
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