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. "Your pain will gradually become less severe." This statement is accurate and provides realistic expectations for the client. After an amputation, there will be initial post operative pain, but it should gradually decrease over time.
B. "The pain will disappear soon." This statement is not accurate. While the pain will eventually decrease, it may not completely disappear immediately after the procedure.
C. "It's likely that you will have only a tingling sensation." This statement is not accurate. While some clients may experience tingling sensations, it is not the only sensation they may feel, and this statement does not cover the full range of possible experiences.
D. "Phantom pain is mostly psychological." This statement is not accurate. Phantom pain is a real sensation that some individuals experience after an amputation. It is believed to be related to nerve endings that continue to send signals to the brain even though the limb is no longer present. It is not purely psychological.
Correct Answer is ["43.2"]
Explanation
- To calculate the dose of enoxaparin, first convert the client's weight from pounds to kilograms by dividing by 2.2.
- 95 lbs / 2.2 = 43.18 kg
- Then, multiply the weight in kilograms by the prescribed dose of 1 mg/kg. - 43.18 kg x 1 mg/kg = 43.18 mg
- Finally, round the answer to the nearest tenth of a milligram.
- 43.18 mg ≈ 43.2 mg
- Therefore, the nurse should administer 43.2 mg of enoxaparin per dose subcutaneously every 12 hours.
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