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 ["43.2"]

Explanation

- To calculate the dose of enoxaparin, first convert the client's weight from pounds to kilograms by dividing by 2.2.

- 95 lbs / 2.2 = 43.18 kg

- Then, multiply the weight in kilograms by the prescribed dose of 1 mg/kg. - 43.18 kg x 1 mg/kg = 43.18 mg

- Finally, round the answer to the nearest tenth of a milligram.

- 43.18 mg ≈ 43.2 mg

- Therefore, the nurse should administer 43.2 mg of enoxaparin per dose subcutaneously every 12 hours.

A. Performing range of motion B. Checking capillary refill distal to the cast C. Teaching the client about cast care D. Managing pain

Correct Answer is B

Explanation

A. Performing range of motion: This should not be done immediately after applying the cast, as it may compromise the integrity of the cast. Range of motion exercises should be initiated once the cast has fully set and as directed by the healthcare provider.

B. Checking capillary refill distal to the cast: This is the priority after applying the cast. It assesses blood flow to the extremity below the cast. Impaired circulation could lead to serious complications, so it's crucial to monitor capillary refill promptly.

C. Teaching the client about cast care: While providing education about cast care is important, it is not the immediate priority. Ensuring proper circulation is more critical in the initial moments after applying the cast.

D. Managing pain: While pain management is important, it is not the immediate priority after applying the cast. Ensuring proper circulation and assessing for any signs of impairment take precedence. Pain management can be addressed once circulation is confirmed to be adequate.

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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

Correct Answer is ["43.2"]

Explanation

A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast?

Correct Answer is B

Explanation

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