A nurse is collecting data from a client who has skeletal traction.

Which of the following findings should the nurse identify as an indication of infection at the pin sites?

Warmth.

Mild erythema.

Serosanguineous drainage.

Fever.

Answer and Explanation

The Correct Answer is D

Fever is a sign of infection and can indicate that there is an infection at the pin sites.

Choice A is not correct because warmth can be a normal finding at the pin sites.
Choice B is not correct because mild erythema can be a normal finding at the pin sites.
Choice C is not correct because serosanguineous drainage can be a normal finding at the pin sites.

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Correct Answer is C

Explanation

The nurse should check for blood under the client’s buttocks.
A small amount of lochia rubra on the client’s perineal pad 4 hours postpartum is normal.
The fundus being midline and firm at the umbilicus is also a normal finding.
Choice A is incorrect because assisting the client to ambulate is not necessary at this time.
Choice B is incorrect because there is no need to increase the rate of IV fluids.
Choice D is incorrect because performing a fundal massage is not necessary since the fundus is already firm and midline.

A. Encephalopathy. B. Encopresis. C. Enuresis. D. Echolalia.

Correct Answer is B

Explanation

Encopresis is the repeated passage of feces into inappropriate places such as clothing or the floor by a child who is already toilet trained.
Choice A is not correct because encephalopathy refers to a disease or disorder that affects the brain.
Choice C is not correct because enuresis refers to involuntary urination, especially by children at night.
Choice D is not correct because echolalia refers to the repetition of vocalizations made by another person.

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A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

The nurse is collecting data from the caregiver of an 8-year-old child who recently started soiling his underwear each day rather than using the toilet to defecate. This behavior indicates a symptom of:

Correct Answer is B

Explanation

A nurse is collecting data on an adolescent client who has attention deficit hyperactivity disorder (ADHD). Which of the following manifestations should the nurse expect to find?

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A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

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A nurse is collecting data from a client who has skeletal traction.

Which of the following findings should the nurse identify as an indication of infection at the pin sites?