A nurse is collecting data from a client that is 48 hours post-operative following and open reduction and internal fixation of a fractured tibia. Which of the following findings should the nurse report to the provider?

Toes cold to touch

Pink tissue around the pin sites

Blanching of the toenail beds with pressure.

Serious drainage from the pin sites

Answer and Explanation

The Correct Answer is A

A. Toes cold to touch: Cold toes can indicate compromised circulation, potentially due to compartment syndrome or other vascular issues, and should be reported immediately.

B. Pink tissue around the pin sites: Pink tissue around the pin sites usually indicates normal healing and is not generally a cause for concern unless accompanied by other symptoms of infection or inflammation.

C. Blanching of the toenail beds with pressure: Blanching of the toenail beds with pressure is a normal finding in assessing capillary refill and does not typically indicate a serious issue on its own.

D. Serous drainage from the pin sites: Serous drainage (clear, yellowish fluid) is common and expected post-operatively and does not usually indicate an infection or other complication unless there are additional concerning symptoms.

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Correct Answer is D

Explanation

A. Provide an elevated toilet seat: This is important for preventing hip dislocation but is not the immediate priority.
B. Assist out of bed immediately following surgery: Mobilizing the patient is important to prevent complications such as deep vein thrombosis (DVT) and pneumonia, but this should be done safely and as prescribed.
C. Medicate with pain medications: Pain management is crucial for postoperative recovery but is part of comprehensive care rather than the single priority.
D. Maintain weight bearing as prescribed: Following weight-bearing restrictions is critical to ensure proper healing and prevent complications such as dislocation or prosthetic failure. This is the immediate priority in terms of preventing harm and ensuring recovery.

A. Provide relief from pain and discomfort for the client. B. Maintain immobilization and alignment for the client. C. Promote independence in activities of daily living for the client. D. Provide optimal nutrition and hydration for the client.

Correct Answer is B

Explanation

A. Provide relief from pain and discomfort for the client: Pain relief is important but not the highest priority for functional healing.

B. Maintain immobilization and alignment for the client: This is the highest priority because proper immobilization and alignment are crucial for bone healing and preventing complications.

C. Promote independence in activities of daily living for the client: Promoting independence is important but secondary to ensuring proper healing through immobilization and alignment.

D. Provide optimal nutrition and hydration for the client: Nutrition and hydration are essential for overall health and healing but are not as immediate in priority as maintaining immobilization and alignment for proper bone healing.

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A nurse is collecting data from a client that is 48 hours post-operative following and open reduction and internal fixation of a fractured tibia. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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