A nurse is collecting data from a client who has skeletal traction.

Which of the following findings should the nurse identify as an indication of infection at the pin sites?

Warmth.

Mild erythema.

Serosanguineous drainage.

Fever.

Answer and Explanation

The Correct Answer is D

Fever is a sign of infection and can indicate that there is an infection at the pin sites.

Choice A is not correct because warmth can be a normal finding at the pin sites.
Choice B is not correct because mild erythema can be a normal finding at the pin sites.
Choice C is not correct because serosanguineous drainage can be a normal finding at the pin sites.

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Correct Answer is C

Explanation

A full bladder can displace the uterus and cause it to deviate to one side.
Choice A is not correct because a temperature of 37.7° C (100° F) is within the normal range for a postpartum client.
Choice B is not correct because the client’s milk production is not related to the findings noted by the nurse.
Choice D is not correct because there is no indication that the client needs an increase in IV fluids.

A. Has blue-looking nail beds on the toes. B. Has a weak femoral pulse. C. Cannot plantarflex his foot. D. Feels increasing severe pain.

Correct Answer is D

Explanation

Compartment syndrome is a condition where increased pressure within a muscle compartment causes muscle and nerve damage along with pain.
One of the symptoms of compartment syndrome is severe pain that increases with the stretching of muscles.

Choice A is not correct because blue-looking nail beds on the toes are not a symptom of compartment syndrome.
Choice B is not correct because a weak femoral pulse is not a symptom of compartment syndrome.
Choice C is not correct because the inability to plantarflex the foot is not a symptom of compartment syndrome.

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A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F); pulse rate 88/min; respiratory rate 18/min. Which of the following actions should the nurse perform?

Correct Answer is C

Explanation

The nurse caring for a child who has been put into a leg cast must be on alert for signs of nerve and muscle damage. Which symptom might be an early warning signal that the child has developed compartment syndrome?

Correct Answer is D

Explanation

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A nurse is collecting data from a 10-month-old infant. Which of the following findings should the nurse report to the provider?

A nurse is collecting data from a client who has skeletal traction.

Which of the following findings should the nurse identify as an indication of infection at the pin sites?