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 C
Explanation
Choice A rationale
A mesh-like device within the catheter that springs open is characteristic of a stent, not a balloon-tipped catheter used in PTCA. Stents are often used in conjunction with angioplasty to keep the artery open after the balloon has compressed the plaque.
Choice B rationale
While catheters can be used to take pressure measurements, this is not the primary function of the balloon-tipped catheter in PTCA. The main purpose of the balloon-tipped catheter is to compress the plaque against the artery wall to improve blood flow.
Choice C rationale
The balloon-tipped catheter in PTCA is used to compress the plaque against the coronary blood vessel wall. This process, known as balloon angioplasty, helps to widen the artery and improve blood flow to the heart.
Choice D rationale
Cutting away plaque with an embedded blade is a description of atherectomy, not PTCA. Atherectomy involves a different type of catheter designed to remove plaque from the artery wall.
Correct Answer is C
Explanation
Choice A rationale
Friction rub is not a typical complication of endocarditis. It is more commonly associated with pericarditis, which is inflammation of the pericardium.
Choice B rationale
Intermittent claudication is not a complication of endocarditis. It is typically associated with peripheral artery disease, which affects blood flow to the limbs.
Choice C rationale
Cardiac murmur is a common finding in endocarditis. The infection can cause damage to the heart valves, leading to abnormal heart sounds or murmurs.
Choice D rationale
Dependent rubor is not a complication of endocarditis. It is usually associated with peripheral artery disease and is characterized by redness of the lower extremities when they are in a dependent position.
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