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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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. "I have a set of my brother's crutches in my basement that I can also use.

Crutches must be individually fitted to the user’s height and arm length to prevent nerve injury and ensure safe mobility. Using another person’s crutches is unsafe.

B. "I will keep spare crutch tips handy."

Crutch tips can wear out or become slippery. Keeping extras on hand is a good safety measure.

C. "I will bear the weight of my body on my hands."

Weight should be borne through the hands and not the underarms to avoid brachial nerve damage (crutch palsy).

D. "I will inspect my crutches every day for signs of wear."

Daily inspection of crutch tips and padding helps ensure safety and durability.

A. Abduction B. External rotation C. Internal rotation D. Adduction

Correct Answer is A

Explanation

A. Abduction:

Abduction refers to movement of a limb away from the midline of the body, such as raising the arm from the side outward and upward.

B. External rotation:

This refers to rotating a limb outward along its axis, not raising the arm overhead.

C. Internal rotation:

This refers to rotating the limb inward, which is not the action of lifting the arm above the head.

D. Adduction:

Adduction refers to moving a limb toward the midline, the opposite of abduction.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further reinforcement of teaching?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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