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 C

Explanation

C. Excessive sanguineous fluid in the drain could indicate active bleeding or a hematoma formation, which are significant concerns after surgery. It should be reported to allow for appropriate intervention to prevent shock

A. A slight elevation in temperature can be expected in the immediate postoperative period due to the body's response to surgery (surgical stress response).

B. Fine crackles indicate the presence of fluid in the lungs, which could suggest complications such as pulmonary edema or atelectasis. While this finding warrants monitoring and intervention, it may not be the most critical issue to report to the surgeon in this context.

D. Redness and swelling along the suture line can indicate inflammation or infection at the surgical site. This is a normal response of the tissues to trauma such as surgery.

A. Provide a thorough explanation of the planned surgical procedure. B. Notify the surgeon that the informed consent process is not complete. C. Notify the operating room nurse to give a complete explanation of the procedure. D. Give the prescribed preoperative antibiotics and withhold sedative medications.

Correct Answer is B

Explanation

B. If the patient expresses confusion or uncertainty about the surgical procedure, the nurse should notify the surgeon or appropriate healthcare provider promptly. The surgeon may need to revisit the discussion with the patient, clarify any misunderstandings, and answer any questions to ensure informed consent.

A. This option involves the nurse providing the patient with a comprehensive explanation of the planned surgical procedure, including the purpose, risks, benefits, and alternatives. That however, is the role of the provider.

C. While the operating room nurse may have knowledge about the planned surgical procedure, it is ultimately the responsibility of the surgeon or healthcare provider performing the procedure to ensure that the patient understands and consents to the surgery.

D. Administering preoperative antibiotics and managing sedative medications are important aspects of preoperative care but are not directly related to addressing the patient's concerns about understanding the planned surgical procedure.

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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.)

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