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 A

Explanation

This description accurately reflects a greenstick fracture. In a greenstick fracture, the bone is partially fractured, typically on one side, while the other side remains intact. It is often compared to the way a green stick bends but does not break completely.

This description is more characteristic of a comminuted fracture, where the bone breaks into multiple fragments that may displace or splinter into the surrounding tissue.

This description is indicative of an impacted fracture, where the bone ends are driven into each other, often due to a compressive force.

This description is characteristic of an open or compound fracture, where the broken bone penetrates the skin and is exposed to the external environment.

A. Venous thromboembolism B. Fluid and electrolyte imbalance C. Impaired surgical wound healing D. Hypovolemic shock

Correct Answer is A

Explanation

A. Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant concern following knee replacement surgery due to the increased risk of blood clot formation associated with immobility and surgery. Limited mobility can predispose the patient to stasis of blood flow, which increases the risk of VTE.

B. While fluid and electrolyte imbalance can occur postoperatively, especially if the patient experiences complications such as excessive bleeding or fluid shifts, limited mobility alone is less likely to directly lead to this complication as a priority.

C. Limited mobility can potentially impact surgical wound healing by delaying the resolution of edema, impairing circulation, and increasing the risk of infection. However, this complication may not be as immediate or life-threatening as others on the list.

D. Hypovolemic shock, characterized by inadequate tissue perfusion due to decreased circulating blood volume, is a severe complication that can result from significant blood loss. While bleeding can occur postoperatively, it is less common as a complication of knee replacement surgery, especially within the first few days.

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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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Naxlex Comprehensive Predictor Exams

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