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?

Mild erythema

Serosanguineous drainage

Fever

Warmth

Answer and Explanation

The Correct Answer is C

A. Mild erythema (redness) at the pin sites can be a normal finding due to the body's response to the presence of foreign objects. It may not necessarily indicate infection.

B. Serosanguineous drainage (a mixture of clear and bloody fluid) can also be a normal finding initially after the insertion of pins. It may not necessarily indicate infection.

C. Fever is a systemic response to infection. In a client with skeletal traction, fever can be an indication of an infection at the pin sites or a more systemic infection related to the traction device.

D. Warmth around the pin sites can be a normal finding due to the inflammatory response that occurs after pin insertion. It may not necessarily indicate infection.

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Correct Answer is C

Explanation

A. Twisting at the waist while lifting or moving an object can strain the back muscles and potentially lead to injury. The nurse should advise against this.

B. Relaxing the abdominal muscles while lifting an object can lead to inadequate support for the spine, potentially causing further strain or injury. The nurse should instruct the client to engage the abdominal muscles for stability.

C. Correct. Bending at the knees when picking up an object helps distribute the weight more evenly and reduces strain on the back muscles. This is a safe and recommended technique for lifting.

D. Holding an object away from the body while lifting it can increase the strain on the back muscles. The client should be advised to keep the object close to their body for better support and balance.

A. Remove the weights for a few minutes each hour. B. Apply lotion to the skin under the edges of the splint. C. Apply a foot plate to the bed. D. Reposition the client to keep him from staying in the same position in bed.

Correct Answer is D

Explanation

A. Removing the weights periodically helps relieve pressure on the skin but dosen't preventpressure points from developing.

B. Applying lotion may not effectively prevent pressure points and could potentially lead to skin irritation.

C. Applying a foot plate to the bed is not directly related to preventing pressure points around the edges of the splint.

D. Repositioning the client is important for overall comfort as well as preventing complications by altering pressure points.

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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?

Nursing Test Bank

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