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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Fat embolism syndrome - This is characterized by respiratory distress, altered mental status, and petechial rash. It is not associated with increasing edema.
B. Pulmonary embolism - This occurs when a blood clot (usually from the legs) travels to the lungs and can present with symptoms like chest pain, shortness of breath, and rapid heart rate. It is not associated with increasing edema around a fracture site.
C. Acute compartment syndrome - This is a serious condition that occurs when increased pressure within a muscle compartment impairs blood supply, leading to tissue ischemia and necrosis. Increasing edema is an early sign of compartment syndrome.
D. Osteomyelitis - This is an infection of the bone and is not typically associated with increasing edema around a fracture site. It may present with local signs of infection like warmth, redness, and tenderness.
Correct Answer is ["32"]
Explanation
1. Determine the concentration of heparin in the solution:
- There are 25,000 units of heparin in 500 mL of D5W.
- Concentration = 25,000 units / 500 mL = 50 units/mL.
2. Calculate the required mL/hr for the desired infusion rate:
- The order is for 1600 units/hr.
- To find the mL/hr:
ML/HR=desired units/hr divided by unts/ml
=1600/50
=32ml/hr
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