A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.)
Elastic bandages secure around the traction ropes
Minimal edema around the pin
Slight pain at the insertion site
Serous drainage on the dressing
Movement of the pin at the insertion site
Correct Answer : B,C,D
B. Minimal edema (swelling) around the pin insertion site is an expected finding in clients with skeletal traction. Some degree of swelling may occur due to tissue trauma and the presence of foreign objects (such as the traction pins) within the soft tissues.
C. Slight pain or discomfort at the pin insertion site is common in clients with skeletal traction. The presence of traction pins can cause irritation or discomfort, especially during movement or weight- bearing activities.
A. Elastic bandages are not typically used to secure traction ropes in skeletal traction. Traction is usually maintained using specialized devices or weights attached to the traction ropes.
D. A small amount of clear, watery drainage is normal. This is the body's natural response to injury.
E. Movement of the pin at the insertion site is not an expected finding and may indicate inadequate stabilization or loosening of the pin. The pins should be securely anchored to the bone to maintain proper traction and stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The most appropriate first action would be to increase the oxygen flowrate to improve the patient's oxygen saturation levels. This intervention directly addresses the hypoxemia and can help prevent further complications related to low oxygen levels in the blood.
B. Elevating the patient's head can help improve ventilation and oxygenation. By raising the head, the patient's airway may become more patent, allowing for better airflow and oxygen exchange in the lungs. However, this should follow oxygenation.
C. Suctioning the patient's mouth aims to remove any secretions or obstructions that may be compromising the airway and contributing to the low oxygen saturation. However, this should follow oxygenation.
D. This maneuver can be helpful if the airway is obstructed by the tongue or soft tissues, potentially improving ventilation and oxygenation. However, this should follow oxygenation.
Correct Answer is D
Explanation
D. Excessive thyroid hormone replacement therapy, leading to hyperthyroidism, can accelerate bone turnover and increase the risk of osteoporosis. Hyperthyroidism can disrupt normal bone remodeling processes, leading to decreased bone mineral density and increased fracture risk.
A. NSAIDs are commonly used to reduce inflammation and relieve pain. While short-term or occasional use of NSAIDs is generally safe, long-term use or high doses of NSAIDs may be associated with an increased risk of osteoporosis and bone fractures.
B. Anticoagulants, such as warfarin and heparin, are medications used to prevent blood clot formation. While anticoagulants themselves are not directly associated with osteoporosis risk, prolonged immobilization due to conditions requiring anticoagulation therapy (such as deep vein thrombosis or pulmonary embolism) can increase the risk of osteoporosis and bone loss due to decreased weight- bearing activity.
C. Cardiac glycosides, such as digoxin, are medications used to treat heart failure and certain cardiac arrhythmias. There is no direct evidence to suggest that cardiac glycosides themselves are a risk factor for osteoporosis.
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