An anxious patient in skeletal traction is distressed by the clear fluid drainage that is oozing from the pin sites. The nurse's best intervention would be to:
cover the pin with several gauze pads and tape securely.
assure the patient that such drainage is expected.
notify the charge nurse of possible infection.
wipe off drainage with a damp wash cloth.
The Correct Answer is B
A. Cover the pin with several gauze pads and tape securely:
This may trap moisture and increase infection risk. Pin sites need to be monitored and cleaned regularly.
B. Assure the patient that such drainage is expected:
Serous drainage is a normal finding after pin insertion. Reassurance is appropriate unless signs of infection are present.
C. Notify the charge nurse of possible infection:
This may be premature without signs of infection (e.g., purulent drainage, redness, fever).
D. Wipe off drainage with a damp wash cloth:
This is not a sterile technique and may introduce infection. Pin site care should follow sterile protocol.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. True
Immobility can lead to urinary stasis, which increases the risk of urinary tract infections (UTIs). Monitoring for urinary symptoms is essential to detect these complications early.
Correct Answer is ["A","B","C","D"]
Explanation
A. Loss of calcium from bone matrix
Immobility causes bone demineralization, increasing the risk for osteoporosis and fractures.
B. Stasis of respiratory secretions
Lack of movement decreases chest expansion, leading to retained secretions and risk of pneumonia or atelectasis.
C. Increased cardiac workload
Immobilization leads to venous stasis and reduced venous return, increasing cardiac workload and risk of thromboembolism.
D. Decreased circulation from pressure
Prolonged pressure leads to reduced perfusion, increasing risk for pressure ulcers.
E. Increased mental activity
Immobilization often results in decreased mental stimulation, potentially leading to depression or confusion, especially in older adults.
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