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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?

A.

Mild erythema

B.

Serosanguineous drainage

C.

Fever

D.

Warmth

Answer and Explanation

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 C

Explanation

A. Fat embolism syndrome - This is characterized by respiratory distress, altered mental status, and petechial rash. It is not associated with increasing edema.

B. Pulmonary embolism - This occurs when a blood clot (usually from the legs) travels to the lungs and can present with symptoms like chest pain, shortness of breath, and rapid heart rate. It is not associated with increasing edema around a fracture site.

C. Acute compartment syndrome - This is a serious condition that occurs when increased pressure within a muscle compartment impairs blood supply, leading to tissue ischemia and necrosis. Increasing edema is an early sign of compartment syndrome.

D. Osteomyelitis - This is an infection of the bone and is not typically associated with increasing edema around a fracture site. It may present with local signs of infection like warmth, redness, and tenderness.

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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