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. Asking the client to wiggle their toes assesses motor function and nerve integrity. In a neurovascular assessment, intact nerve function is crucial, as impaired nerve function can manifest as weakness or paralysis.

A. This technique assesses the circulation in the lower extremity by checking for the presence, strength, and symmetry of the pulse. However, it assesses for vascular component proximal to the fracture.

B. Edema in the calf muscle is mostly used as a marker for deep venous thrombosis. Although it can affect circulation. It may be a late sign.

D. Significant differences in thigh circumference between the affected and unaffected limb may indicate vascular compromise or other issues. This is however, a late sign of vascular compromise.

A. The patient reports abdominal pain when ambulating. B. The patient has fluid intake 600 mL greater than the output. C. The patient's calf is swollen and warm to touch. D. The patient's temperature is 100.3° F (37.9° C).

Correct Answer is C

Explanation

C. The patient's calf being swollen and warm to touch is concerning for a possible deep vein thrombosis (DVT), a clot formation in the deep veins of the leg. DVT is a serious complication post-surgery that requires immediate attention to prevent the clot from dislodging and causing a pulmonary embolism (PE), which can be life-threatening.

A. Abdominal pain after a total abdominal hysterectomy is common and can be expected due to the surgical incision and manipulation of abdominal tissues.

B. Fluid balance is important postoperatively to prevent complications like dehydration or fluid overload. A significant imbalance, with intake substantially greater than output, could indicate issues which may require intervention. However, this is not as urgent as a client with likely DVT.

D. A slight increase in temperature is common in the immediate postoperative period due to the body's response to tissue injury. While it could indicate infection, it's not necessarily alarming on its own.

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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.)

Nursing Test Bank

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