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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Applying ice to the affected knee is a common postoperative instruction after arthroscopic knee surgery. Ice helps reduce swelling, inflammation, and pain in the surgical area. It is usually recommended to apply ice intermittently for short periods during the first 24 to 48 hours following surgery.
A. Keeping the leg in a dependent position, where it is hanging down, is not typically recommended following arthroscopic knee surgery.
C. Complete bedrest for the first 24 hours after arthroscopic knee surgery is not typically necessary or recommended. Early mobilization and gentle range of motion exercises are usually encouraged to prevent complications such as blood clots and joint stiffness.
D. These exercises help restore joint mobility, prevent stiffness, and promote healing of the surgical site. However, the timing and specific exercises should be guided by the surgeon's instructions and individual patient factors.
Correct Answer is D
Explanation
D. Cyclosporine is typically taken on an empty stomach, either 1 hour before or 2 hours after a meal, to improve absorption. Taking it with food, especially high-fat meals, can decrease absorption and effectiveness.
A. Grapefruit juice can interact with cyclosporine, leading to increased blood levels of the medication and potentially causing toxicity. Therefore, clients should be advised to avoid grapefruit juice when taking cyclosporine.
B. Mixing cyclosporine oral solution with chocolate milk or any other liquid should be done only if directed by the healthcare provider or as specified in the medication instructions.
C. Using a plastic container to mix the oral solution may reduce the risk of interaction compared to using metal or glass containers. However, it's important to follow the specific instructions provided with the medication.
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