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 D

Explanation

D. Cyclosporine is typically taken on an empty stomach, either 1 hour before or 2 hours after a meal, to improve absorption. Taking it with food, especially high-fat meals, can decrease absorption and effectiveness.

A. Grapefruit juice can interact with cyclosporine, leading to increased blood levels of the medication and potentially causing toxicity. Therefore, clients should be advised to avoid grapefruit juice when taking cyclosporine.

B. Mixing cyclosporine oral solution with chocolate milk or any other liquid should be done only if directed by the healthcare provider or as specified in the medication instructions.

C. Using a plastic container to mix the oral solution may reduce the risk of interaction compared to using metal or glass containers. However, it's important to follow the specific instructions provided with the medication.

A. Heart rate. B. Oxygen saturation C. Edema D. Temperature E. Urine color F. Pedal pulses

Correct Answer is ["A","D"]

Explanation

A. The heart rate has increased from 92/min on Day 1 to 108/min on Day 2. This significant increase warrants immediate follow-up as it may indicate pain, anxiety, or an underlying physiological issue such as hemorrhage, infection, or cardiac complications.

D. The temperature has increased from 36.4°C (97.5°F) on Day 1 to 37.2°C (98.9°F) on Day 2. While this increase is within a relatively normal range, it is approaching a fever range (> 38°C or 100.4°F) and warrants further evaluation to determine if there is an underlying infection or inflammation.

B. The oxygen saturation remains relatively stable, from 95% on Day 1 to 96% on Day 2. While it is important to monitor oxygen saturation, the minimal change does not indicate an immediate concern. However, it should still be monitored closely for any further decrease.

C. Edema is not directly mentioned in the provided data. While edema can be indicative of various health issues, there is no evidence in the given information to suggest its presence or severity as a concern requiring immediate follow-up.

E. Urine color is not provided in the given data. While changes in urine color can indicate dehydration or other health issues, it is not mentioned in the assessment findings and therefore not a factor for immediate follow-up based on the information provided.

F Pedal pulses were noted as +2 on Day 1, indicating that they were present and normal. Unless there is a significant change in pedal pulses or signs of vascular compromise, such as decreased or absent pulses, there is no immediate need for follow-up based on the given information.

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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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