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. Pallor of the toes indicates compromised blood flow and is the earliest sign of circulatory impairment due to tightness of the cast.

A. Inability to move toes may be a sign of tightness in the cast, but it is not the first finding to be expected if the cast is too tight.

C. Change in temperature of the toes may be a sign of impaired circulation, but it is not the earliest finding to be expected.

D. Edema of the toes may occur as a result of compromised circulation, but it is not the first finding to be expected if the cast is too tight.

A. A client who has protein calorie malnutrition B. A client who has type1 diabetes mellitus and is hyperglycemic C. A client who has right-sided heart failure and 4+ edema to the lower extremities D. A client who has postoperative delirium E. A client who is ambulatory following a cardiac catheterization 4 hr ago

Correct Answer is ["A"]

Explanation

A. Protein-calorie malnutrition can lead to decreased tissue integrity and delayed wound healing, increasing the risk of pressure ulcer development due to compromised nutritional status.

B. Diabetes, especially when uncontrolled, can lead to poor circulation and neuropathy, which increases the risk of pressure ulcers. Hyperglycemia can also impair wound healing and compromise the immune response, further contributing to the risk.

C. Edema increases pressure on the skin and underlying tissues, impairing circulation and increasing the risk of pressure ulcers, especially in areas where there is constant pressure or friction against surfaces.

D. A client with postoperative delirium is not necessarily at risk of delirium.

E. A client post cardiac catheterization and already ambulating is not at risk of pressure sores

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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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