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 ["A","B","E"]
Explanation
Wound infection is a significant risk factor for dehiscence. Infections can weaken the wound edges and delay healing, increasing the likelihood of the wound reopening.
Choice B rationale
Obesity is a risk factor for dehiscence because excess adipose tissue can place additional stress on the wound, impair blood flow, and delay healing.
Choice C rationale
Altered mental status is not directly associated with an increased risk of dehiscence. While it may affect a patient’s ability to follow postoperative care instructions, it is not a primary risk factor.
Choice D rationale
Pain medication administration is not a risk factor for dehiscence. Pain management is essential for recovery and does not contribute to wound reopening.
Choice E rationale
Poor nutritional state is a risk factor for dehiscence because adequate nutrition is essential for wound healing. Malnutrition can impair the body’s ability to repair tissues and increase the risk of wound complications.
Correct Answer is A
Explanation
Choice A rationale
Weak pedal pulses indicate vascular compromise, which is a complication of Buck’s traction. This can be caused by pressure on the tissues of the leg.
Choice B rationale
Complaints of leg discomfort are expected due to the traction and do not indicate a complication.
Choice C rationale
Toes that are warm and demonstrate brisk capillary refill are normal findings and do not indicate a complication.
Choice D rationale
Drainage at the pin sites is more relevant to skeletal traction, not Buck’s traction.
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