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 D
Explanation
A. Protective isolation is not routinely required for clients following scoliosis repair unless there is an underlying infection risk.
B. A PCA pump may be used for pain control, but it is not specific to post-scoliosis repair care.
C. Keeping the head of the bed at 30° is not required; positioning should focus on spinal alignment.
D. Log rolling the client every 4 hours is essential to maintain spinal alignment, prevent complications, and ensure safety following Harrington rod instrumentation.
Correct Answer is C
Explanation
A. Remove the elastic bandage and re-wrap the stump once per day: This is not recommended. The elastic bandage provides support and helps reduce swelling. It should only be removed and re-wrapped as directed by the healthcare provider.
B. Secure the elastic bandage to the lowest joint: The bandage should be secure, but it should not be tied too tightly or secured directly over a joint. This could restrict blood flow and cause discomfort.
C. Wrap the stump with an elastic bandage in a figure-eight configuration: This is the correct action. A figure-eight configuration helps distribute pressure evenly, providing support and reducing the risk of edema and complications.
D. Perform passive range-of-motion exercises once daily: Range-of-motion exercises are important, but they should be performed within the parameters set by the healthcare provider. They should not be performed only once daily, and it's essential to avoid overexertion or straining the residual limb.
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