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 B

Explanation

A. An IV infusion pump may be needed for intravenous therapy but is not specific to postoperative care following intermaxillary fixation.

B. This option is correct. Wire cutters are essential equipment in case of an emergency that requires the removal of the fixation wires.

C. An NG tube may be necessary for nutritional support, but it is not directly related to postoperative care following intermaxillary fixation.

D. A urinary catheter tray is not specific to postoperative care following intermaxillary fixation and may not be a priority in this situation.

A. Increase the client's protein intake. B. Administer antibiotics to the client. C. Provide the client with antipyretic therapy. D. Teach relaxation breathing to reduce the client's pain.

Correct Answer is B

Explanation

A. Increasing the client's protein intake is important for overall healing, but it is not the top priority in the acute phase of osteomyelitis. The immediate priority is to administer antibiotics to address the infection.

B. This is the correct answer. Administering antibiotics is the top priority in the treatment of acute osteomyelitis. Timely administration of appropriate antibiotics is crucial in eradicating the infection and preventing further complications.

C. Providing the client with antipyretic therapy (to reduce fever) is important, but it is secondary to administering antibiotics. The underlying infection must be addressed first and foremost.

D. Teaching relaxation breathing to reduce pain may be beneficial for the client's comfort, but it is not the priority intervention. Controlling the infection with antibiotics takes precedence.

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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

Naxlex Comprehensive Predictor Exams

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