The practical nurse (PN) assesses a child in 90-90 skeletal traction. It is most important for the PN to assess for signs of inflammation at which location? (Select the correct location on the image)
The Correct Answer is "{\"xRanges\":[209.4270782470703,249.4270782470703],\"yRanges\":[92.1666259765625,132.1666259765625]}"
A. Based on the understanding of 90-90 skeletal traction and the common complications associated with pin sites, the practical nurse should focus on assessing the areas around the pin insertion sites in the femur and possibly the tibia for any signs of inflammation.
B. the back is not the correct location
C. The sole of the foot is not the correct location
D. The unaffected limb is not the appropriate location.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E","G"]
Explanation
A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up
Correct Answer is "{\"xRanges\":[209.4270782470703,249.4270782470703],\"yRanges\":[92.1666259765625,132.1666259765625]}"
Explanation
A. Based on the understanding of 90-90 skeletal traction and the common complications associated with pin sites, the practical nurse should focus on assessing the areas around the pin insertion sites in the femur and possibly the tibia for any signs of inflammation.
B. the back is not the correct location
C. The sole of the foot is not the correct location
D. The unaffected limb is not the appropriate location.
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