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. Extend one leg and allow the client to slide down the leg to the floor.
It helps to control the fall, protects the client from injury, and allows the nurse to safely guide the client to the floor without using excessive force.
B. Move both feet together when the client begins to fall.
Keeping the feet together reduces stability and increases the risk of both the client and nurse falling.
C. Wrap both arms around the client's arm and shoulders.
This could cause injury to the client’s upper body and doesn't provide support for a safe fall.
D. Protect the client's extremities while lowering them to the floor.
While protecting extremities is important, the nurse’s primary action should be to use proper body mechanics (like extending one leg) to safely lower the client.
Correct Answer is B
Explanation
A. Left the patient with the lap robe tucked underneath.
A lap robe is used for warmth and comfort; tucking it under does not pose a risk.
B. Left the brakes of the wheelchair unlocked.
Wheelchair brakes must be locked during transfers to prevent the chair from moving and causing a fall.
C. Placed the patient's feet centered on the footrests.
Feet should be properly placed to avoid dragging or injury.
D. Placed slippers on the patient.
This is appropriate as long as the slippers are non-skid, providing safe footing during transfer.
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