The nurse is evaluating the pin sites of a client who has been in skeletal traction for 24 hours. The nurse would be least concerned with which finding?
Purulent drainage
Clear, serous drainage
Pain at the pin site, purulent drainage
Inflammation and purulent drainage
The Correct Answer is B
Rationale:
A. Purulent drainage is a sign of possible infection and requires prompt evaluation and intervention.
B. Clear, serous drainage is expected in the first 24 to 72 hours after pin placement and is not typically a cause for concern. It is a normal part of the healing process.
C. Pain combined with purulent drainage suggests infection, which is a serious complication of skeletal traction.
D. Inflammation and purulent drainage are both signs of possible infection at the pin site and warrant further investigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Electrolyte imbalances, particularly hypokalemia and hyponatremia, are common during an acute exacerbation of ulcerative colitis due to frequent diarrhea. Reviewing these values is the priority because severe imbalances can lead to life-threatening complications.
B. A dietary history is important but not the immediate priority in an acute situation.
C. Checking skin integrity is necessary to prevent breakdown, but it follows after addressing potential systemic issues.
D. Addressing emotional concerns is important for holistic care but is not urgent in the acute phase of illness.
Correct Answer is B
Explanation
Rationale:
A. Purulent drainage is a sign of possible infection and requires prompt evaluation and intervention.
B. Clear, serous drainage is expected in the first 24 to 72 hours after pin placement and is not typically a cause for concern. It is a normal part of the healing process.
C. Pain combined with purulent drainage suggests infection, which is a serious complication of skeletal traction.
D. Inflammation and purulent drainage are both signs of possible infection at the pin site and warrant further investigation.
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