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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Overusing a muscle while jogging: This is an example of a strain, which involves muscles or tendons.
B. Crush injury to a bone from blunt trauma: Incorrect. This describes a fracture or a contusion, not a sprain or strain.
C. Impact injury on a joint from a fall: Incorrect. While a fall can cause a sprain, the impact itself is not specific to sprains; it could cause various types of injuries.
D. Twisting a ligament while walking. A sprain involves injury to ligaments, which is consistent with twisting a joint.
Correct Answer is D
Explanation
A. The ropes attach securely to the pin. Secure attachment of the ropes is important but not usually a problem that needs correction.
B. The ropes are in the center of the wheel grooves. Proper placement of the ropes in the wheel grooves is important for smooth movement, but this is not a common problem needing correction.
C. The weights are equal on each side. Ensuring equal weights is important but not typically a problem needing correction as it is usually set up correctly initially.
D. The weights rest against the foot of the bed. Correct. Weights should not rest against the foot of the bed; they must hang freely to maintain proper traction and alignment.
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