An anxious patient in skeletal traction is distressed by the clear fluid drainage that is oozing from the pin sites. The nurse's best intervention would be to:
cover the pin with several gauze pads and tape securely.
assure the patient that such drainage is expected.
notify the charge nurse of possible infection.
wipe off drainage with a damp wash cloth.
The Correct Answer is B
A. Cover the pin with several gauze pads and tape securely:
This may trap moisture and increase infection risk. Pin sites need to be monitored and cleaned regularly.
B. Assure the patient that such drainage is expected:
Serous drainage is a normal finding after pin insertion. Reassurance is appropriate unless signs of infection are present.
C. Notify the charge nurse of possible infection:
This may be premature without signs of infection (e.g., purulent drainage, redness, fever).
D. Wipe off drainage with a damp wash cloth:
This is not a sterile technique and may introduce infection. Pin site care should follow sterile protocol.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. True
Immobility can lead to urinary stasis, which increases the risk of urinary tract infections (UTIs). Monitoring for urinary symptoms is essential to detect these complications early.
Correct Answer is B
Explanation
A. "Keep your head straight and turn it as far as possible to either side."
This is rotation, not hyperextension.
B. "Move your head from the upright position back as far as you can."
This describes hyperextension, which is the movement of the head beyond the neutral upright position.
C. "Move your head so that your chin rests on your chest."
This is flexion, not hyperextension.
D. "Move your head laterally towards your right and left shoulder."
This describes lateral flexion, not hyperextension.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.