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

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. Pallor of the toes indicates compromised blood flow and is the earliest sign of circulatory impairment due to tightness of the cast.

A. Inability to move toes may be a sign of tightness in the cast, but it is not the first finding to be expected if the cast is too tight.

C. Change in temperature of the toes may be a sign of impaired circulation, but it is not the earliest finding to be expected.

D. Edema of the toes may occur as a result of compromised circulation, but it is not the first finding to be expected if the cast is too tight.

A. Palpate the femoral pulse. B. Monitor the client's calf for edema. C. Instruct the client to wiggle his toes. D. Measure the circumference of the thigh.

Correct Answer is C

Explanation

C. Asking the client to wiggle their toes assesses motor function and nerve integrity. In a neurovascular assessment, intact nerve function is crucial, as impaired nerve function can manifest as weakness or paralysis.

A. This technique assesses the circulation in the lower extremity by checking for the presence, strength, and symmetry of the pulse. However, it assesses for vascular component proximal to the fracture.

B. Edema in the calf muscle is mostly used as a marker for deep venous thrombosis. Although it can affect circulation. It may be a late sign.

D. Significant differences in thigh circumference between the affected and unaffected limb may indicate vascular compromise or other issues. This is however, a late sign of vascular compromise.

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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.)

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Naxlex Comprehensive Predictor Exams

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