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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Metal objects, including jewelry, can interfere with the DXA scan and affect the quality of the images. Therefore, it is important for the client to remove all jewelry and metal objects before the test to ensure accurate results.
B. Fasting is not typically required for a dual-energy x-ray absorptiometry (DXA) scan. DXA scans are non- invasive and do not involve the administration of any substances that would necessitate fasting.
C. This instruction is not specifically required for a DXA scan. However, it is generally a good practice for clients to empty their bladder before any imaging test to ensure comfort during the procedure.
D. This instruction is not accurate for a DXA scan. DXA scans are typically quick procedures that do not require the client to lie flat for an extended period afterward. Clients can resume their normal activities immediately following the scan without any restrictions.
Correct Answer is D
Explanation
D. Fractures, crush injuries, or tight casts can lead to compartment syndrome. Symptoms include severe pain, swelling, numbness or tingling, and decreased sensation or function of the affected limb.
Increasing edema in the calf is a hallmark manifestation of acute compartment syndrome and indicates a worsening of the condition.
A. Malignant hyperthermia is a rare but life-threatening complication that can occur in response to certain medications used during anesthesia. Edema in the calf is not a manifestation of malignant hyperthermia.
B. Pulmonary embolism occurs when a blood clot travels to the lungs and blocks blood flow. While pulmonary embolism can cause symptoms such as chest pain, shortness of breath, and cough, edema in the calf is not a typical manifestation of this condition.
C. Fat embolism syndrome occurs when fat globules are released into the bloodstream, often after long bone fractures or orthopedic procedures. Increasing edema in the calf is not a characteristic manifestation of fat embolism syndrome.
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