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. This technique helps to prevent pressure ulcers and assists in maintaining proper spinal alignment, which is essential after such a surgery.
B. Clear drainage on the spinal dressing is not typically expected and could indicate an infection or other complication.
C. Assisting the client to sit upright in a chair for extended periods is not standard practices immediately following spinal fusion, as these actions may put undue stress on the spine during the critical initial healing phase.
D. Elevating the client's legs while sitting are not standard practices immediately following spinal fusion, as these actions may put undue stress on the spine during the critical initial healing phase
Correct Answer is A
Explanation
A. Checking capillary refill distal to the cast helps assess peripheral circulation and nerve function. A decrease in capillary refill time or other signs of compromised circulation (such as coolness, pallor, or numbness) could indicate a complication like compartment syndrome, which requires immediate intervention.
B. Performing range of motion exercises is important for promoting joint mobility and preventing stiffness, but it is not the priority immediately after the cast application.
C. Educating the client about cast care is important for promoting healing and preventing complications, but it is not the priority immediately after the cast application.
D. Managing pain is important for the client's comfort and well-being, but it is not the priority immediately after the cast application.
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