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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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Raise the head of the bed to 30 to 45 degrees.

While head elevation for comfort is acceptable, it is not the primary responsibility for CPM care.

B. Elevate the machine at the foot of the bed on one pillow.

The CPM machine should lie flat along the bed frame. Elevation on a pillow can cause misalignment or malfunction.

C. Set the proper flexion and extension limits.

The nurse must confirm that the machine is set according to the provider's orders for proper range of motion and to prevent injury.

D. Keep the operated knee warm.

While comfort is important, this is not a priority of CPM machine care and doesn't directly relate to its function.

A. Develops fatigue when assisting with morning hygiene care B. Needs assistance raising her legs to put on socks C. Performs active range-of-motion (ROM) exercises of all extremities D. Demonstrates mild dyspnea when eating breakfast

Correct Answer is C

Explanation

A. Develops fatigue when assisting with morning hygiene care

Fatigue during hygiene suggests low endurance; not ready to ambulate safely.

B. Needs assistance raising her legs to put on socks

Needing assistance for simple tasks shows weakness and poor muscle control.

C. Performs active range-of-motion (ROM) exercises of all extremities

Performing full active ROM exercises indicates good muscle strength and coordination, suggesting readiness to attempt ambulation.

D. Demonstrates mild dyspnea when eating breakfast

Dyspnea with minimal activity (eating) indicates limited cardiopulmonary reserve-not yet fit to ambulate.

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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:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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