A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.)

Elastic bandages secure around the traction ropes

Minimal edema around the pin

Slight pain at the insertion site

Serous drainage on the dressing

Movement of the pin at the insertion site

Answer and Explanation

Correct Answer : B,C,D

B. Minimal edema (swelling) around the pin insertion site is an expected finding in clients with skeletal traction. Some degree of swelling may occur due to tissue trauma and the presence of foreign objects (such as the traction pins) within the soft tissues.

C. Slight pain or discomfort at the pin insertion site is common in clients with skeletal traction. The presence of traction pins can cause irritation or discomfort, especially during movement or weight- bearing activities.

A. Elastic bandages are not typically used to secure traction ropes in skeletal traction. Traction is usually maintained using specialized devices or weights attached to the traction ropes.

D. A small amount of clear, watery drainage is normal. This is the body's natural response to injury.

E. Movement of the pin at the insertion site is not an expected finding and may indicate inadequate stabilization or loosening of the pin. The pins should be securely anchored to the bone to maintain proper traction and stability.

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Correct Answer is B

Explanation

B. Alcohol consumption, especially beer and spirits, is associated with an increased risk of gout attacks as it can elevate uric acid levels in the body. Limiting alcohol intake can help prevent gout attacks.

A. While adequate hydration is important for overall health, limiting fluid intake to 1 liter per day may not be appropriate, especially considering that hydration can help prevent gout attacks.

C. While aspirin is commonly used for pain relief, it is not typically recommended for gout management.

D. High-purine foods such as red meat, organ meats, and certain seafood can exacerbate gout symptoms by increasing uric acid levels in the body. Therefore, closely following a high-purine diet would likely worsen gout symptoms rather than improve them.

A. Hold opioid analgesics until the patient is warmer. B. Notify the anesthesia care provider. C. Cover the patient with a warm blanket. D. Give acetaminophen 650 mg suppository rectally.

Correct Answer is C

Explanation

C. Covering the patient with a warm blanket is an appropriate initial intervention to address the patient's hypothermia and shivering. Heat conservation measures, such as using blankets or warming devices, help raise the patient's body temperature and alleviate shivering.

A. While shivering and a low body temperature (hypothermia) can be common postoperative complications, holding opioid analgesics may not directly address the underlying cause of the shivering or hypothermia.

B. Notifying the anesthesia care provider is a prudent action, especially if the patient's shivering and hypothermia are suspected to be related to intraoperative factors such as inadequate warming or anesthesia-induced temperature dysregulation. However, this is not the immediate action.

D. Acetaminophen is not typically indicated as the initial treatment for hypothermia or shivering. While acetaminophen can help reduce fever and discomfort, rectal suppositories may not provide rapid temperature elevation or relief from shivering.

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A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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