NCLEX Exam Practice Question of the Week - 04/20/11

Elsevier NCLEX Exam Review

Question: A nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which of the following findings?

1. Inflammation
2. Serous drainage
3. Pain at a pin site
4. Purulent drainage

Answer: 2

Rationale: A small amount of serous oozing is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported to the physician.

Test-Taking Strategy: Use the process of elimination. Note the strategic words least concerned. Options 1 and 4 seem to indicate an infectious problem and are eliminated first. From the remaining options, note that the complaint of pain is at “a pin site.” Also, because serous drainage is an expected finding, select option 2. Review expected findings in the client with skeletal traction if you had difficulty with this question.

Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—evaluation
Content Area: Adult health—musculoskeletal

Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care. (6th ed., p. 1191). St. Louis: Saunders.

This week’s NCLEX exam practice question can be found in:
Silvestri: Saunders Comprehensive Review for the NCLEX-RN Examination, 5th edition, Chapter 68, Question 831

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