The nurse is performing pin care for a patient with an external fixation device for a fractured tibia. Which assessment finding by the nurse should be reported to the unit care coordinator?
Areas around pins are dry.
Crusts around pins.
Purulent drainage around pins.
Absence of pain at the site.
The Correct Answer is C
Choice A reason: Dry areas around the pins can be a normal finding if the pin sites are healing properly. It indicates that there is no excessive moisture that could promote bacterial growth and infection. However, the nurse should continue to monitor for any signs of redness, swelling, or pain that could indicate a developing infection.
Choice B reason: Crusts around the pins are typically a sign of dried exudate, which can be part of the normal healing process. The crusts should be monitored and cleaned according to the healthcare facility's protocol to prevent infection. If the crusts are accompanied by other signs of infection, such as redness, warmth, or purulent drainage, they should be reported to the healthcare provider.
Choice C reason: Purulent drainage around the pins is a sign of infection and should be reported immediately to the unit care coordinator. Infections at pin sites can lead to complications such as osteomyelitis, delayed healing, or even systemic infection. Prompt intervention with appropriate cleaning and possibly antibiotics is necessary to prevent further complications.
Choice D reason: The absence of pain at the site can be a normal finding and is not typically a cause for concern unless there is an expectation of pain based on the patient's condition or recent procedures. However, a complete lack of sensation could indicate nerve damage or other issues, so the nurse should assess for other signs of neurovascular compromise and report any concerns to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The fluctuation of fluid in the water-seal chamber does not necessarily mean that the lung is fully re-expanded. The water-seal chamber's fluid level fluctuates with the client's breathing because it reflects the changes in intrathoracic pressure.
Choice B reason: The statement "Your breathing pattern causes this" is correct. The fluctuation, also known as tidaling, in the water-seal chamber is normal and occurs in response to the client's breathing. When the client inhales, negative pressure in the chest cavity causes the fluid level to rise, and when the client exhales, the pressure becomes positive, causing the fluid level to fall.
Choice C reason: Suction pressure that is too high can cause continuous bubbling in the suction control chamber but does not directly cause the fluid in the water-seal chamber to rise and fall. The suction control chamber's bubbling should be steady and gentle when the suction is set correctly.
Choice D reason: Continuous bubbling in the water-seal chamber may indicate an air leak, which is a problem that needs to be addressed. However, normal fluctuation with breathing is not indicative of an air leak.
Correct Answer is A
Explanation
Choice A reason : A severe, throbbing headache is a common and significant manifestation of autonomic dysreflexia. This condition is a potentially life-threatening medical emergency that can occur in individuals with spinal cord injuries, typically above the T6 level. The headache results from a sudden and severe increase in blood pressure due to an exaggerated response of the autonomic nervous system to a stimulus below the level of the injury.
Choice B reason: Hypotension, or low blood pressure, is not a manifestation of autonomic dysreflexia. In fact, the condition is characterized by hypertension, or high blood pressure, which is a critical sign that requires immediate attention to prevent complications such as stroke or seizure.
Choice C reason: Fever is not a direct manifestation of autonomic dysreflexia. While a fever may indicate an infection or other systemic issue, autonomic dysreflexia itself is specifically associated with a rapid onset of high blood pressure and other autonomic disturbances.
Choice D reason: Cyanosis of the head and neck, which refers to a bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is not a typical manifestation of autonomic dysreflexia. The condition primarily causes hypertension and its associated symptoms, rather than issues with oxygenation.
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