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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Red skin with edema in the nail beds is more indicative of a superficial injury or inflammation, such as cellulitis or a mild burn, rather than frostbite.

Choice B rationale

Black fingertips surrounded by an erythematous rash suggest gangrene or severe necrosis, which can occur in advanced stages of frostbite but is not an initial finding.

Choice C rationale

A white appearance to the skin that is insensitive to touch is a classic sign of frostbite. The lack of sensation is due to the freezing of tissues and nerves, and the white color indicates a lack of blood flow to the affected area.

Choice D rationale

A pink edematous hand is more indicative of a mild inflammatory response or early stages of frostbite before the tissue has frozen. It does not represent the more severe presentation of frostbite.

A. Potassium level. B. Pre-albumin level. C. History of diabetes mellitus. D. History of hyperlipidemia. E. Wound infection. F. Decreased pedal perfusion. G. Fasting blood glucose.

Correct Answer is ["B","C","E","F","G"]

Explanation

Choice A rationale

Potassium level is not directly related to wound healing. While potassium is essential for overall cellular function, it does not have a direct impact on the wound healing process.

Choice B rationale

Pre-albumin level is a marker of nutritional status. Low pre-albumin levels indicate poor nutrition, which can delay wound healing. Adequate protein intake is essential for the synthesis of collagen and other proteins involved in the wound healing process.

Choice C rationale

History of diabetes mellitus can significantly delay wound healing. High blood glucose levels can impair immune function, reduce blood flow, and increase the risk of infection, all of which can delay the healing process.

Choice D rationale

History of hyperlipidemia is not directly related to wound healing. While hyperlipidemia can contribute to other health issues, it does not have a direct impact on the wound healing process.

Choice E rationale

Wound infection is a major factor that can delay wound healing. Infection can cause inflammation, tissue damage, and increased exudate, all of which can impede the healing process.

Choice F rationale

Decreased pedal perfusion indicates poor blood flow to the extremities. Adequate blood flow is essential for delivering oxygen and nutrients to the wound site, and poor perfusion can delay the healing process.

Choice G rationale

Fasting blood glucose levels are an indicator of blood sugar control. High fasting blood glucose levels can impair immune function and increase the risk of infection, both of which can delay wound healing.

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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?

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Naxlex Comprehensive Predictor Exams

The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?

Correct Answer is C

Explanation

A nurse is caring for a client. Exhibits Select the 5 findings that can cause delayed wound healing.

Correct Answer is ["B","C","E","F","G"]

Explanation

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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?