A nurse is assessing a client who is in skeletal traction.
Which of the following findings should the nurse identify as an indication of infection at the pin sites?
Serosanguineous drainage.
Mild erythema.
Warmth.
Fever.
The Correct Answer is D
Choice A rationale
Serosanguineous drainage is a normal finding at pin sites and does not indicate infection. It is a mixture of serum and blood and is expected during the initial healing phase.
Choice B rationale
Mild erythema around the pin sites can be a normal inflammatory response and does not necessarily indicate infection. It is important to monitor for other signs of infection.
Choice C rationale
Warmth at the pin sites can be a normal finding due to increased blood flow during the healing process. However, it should be monitored in conjunction with other signs of infection.
Choice D rationale
Fever is a systemic sign of infection and indicates that the body is responding to an infectious process. It is a critical finding that requires prompt attention and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A rationale
Fat neck veins are not a typical finding in a client with frequent vomiting and diarrhea. Dehydration, which is common in such cases, usually leads to flat neck veins due to reduced intravascular volume.
Choice B rationale
Hypotension is a common finding in clients with frequent vomiting and diarrhea due to fluid loss and dehydration. The loss of fluids leads to a decrease in blood volume, resulting in low blood pressure.
Choice C rationale
Poor skin turgor is a classic sign of dehydration, which is expected in clients with frequent vomiting and diarrhea. Dehydration causes the skin to lose its elasticity, leading to poor skin turgor.
Choice D rationale
Bradycardia is not typically associated with dehydration. In fact, dehydration often leads to tachycardia (increased heart rate) as the body tries to compensate for the reduced blood volume.
Choice E rationale
Pale yellow urine is not a typical finding in dehydration. Dehydration usually leads to concentrated urine, which is darker in color. Pale yellow urine indicates adequate hydration.
Correct Answer is D
Explanation
According to the Rule of Nines, the percentage of body surface area for different parts of the body is calculated to estimate burn severity. For example, the anterior and posterior aspects of each leg account for 18% each, and the back accounts for 18%. Therefore, the total body surface area burned can be estimated based on these percentages.
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