Week 3: Musculoskeletal and Neuro

The nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as begin at greatest risk for skin breakdown? a. An adolescent who has a cervical fracture and is in a halo brace b. A young adult who has a femur fracture and is in skeletal balanced suspension traction c. A middle adult who has a fractured radius and an arm cast d. An older adult who has a hip fracture and is in Buck's traction

An older adult who has a hip fracture and is in Buck's traction

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take? a. Apply the bag for 30 min at a time b. Reapply the bag 30 min after removing it c. Allow room for some air inside the bag d. Place the bag directly on the skin

Apply the bag for 30 minutes at a time

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric stroke 3 weeks ago. Which of the following goals should the nurse include int he client's rehab program? a. Establish the ability to communicate effectively b. Compensate for loss of depth perception c. Learn to control impulsive behavior d. Improve left-side motor function

Establish the ability to communicate effectively

A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse? a. PaCO2 35 mmHg b. ICP 18 mmHg c. Pulse oximetry 96% d. Blood pressure 140/82 mmHg

ICP 18 mmHg

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? a. Difficulty reading b. Inability to recognize his family members c. Right hemiparesis d. Aphasia

Inability to recognize his family members

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm? a. A bounding distal pulse b. Acute pain c. Ecchymosis of the surrounding skin d. Increasing edema

Increasing edema

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? a. Measure the circumference of the thigh b. Palpate the femoral pulse c. Monitor the client's calf for edema d. Instruct the client to wiggle his toes

Instruct the client to wiggle his toes

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? a. Hypotension b. Tachycardia c. Irritability d. Tinnitus

Irritability

A nurse is developing a plan of care

Maintain immobilization and alignment

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 and suspects the client is experiencing autonomic dysreflexia. Which of the following actions would the nurse take first? a. Administer a nitrate antihypertensive b. Assess the client for bladder distention c. Place the client in high-Fowler's position d. Obtain the client's heart rate

Place the client in high-Fowler's position

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? a. Extension of the arms b. Pronation of the hands c. Plantar flexion of the legs d. External rotation of the lower extremities

Plantar flexion of the legs

A nurse is providing discharge teaching to a client who has a Plaster of Paris walking cast on his lift lower leg. Which of the following instructions should the nurse include? a. Apply ice to your foot after walking b. A musty odor is normal as the cast ages c. There is no need to cover the cast when showering d. Report any numbness or pain in your toes

Report any numbness or pain in your toes

A nurse is caring for a client 4 hours following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority? a. Intracranial pressure b. Serum electrolytes c. Temperature d. Respiratory status

Respiratory status

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect? a. Loss of consciousness lasting 30 to 60 minutes b. Glasgow coma scale of 11 c. Nuchal rigidity d. Sensitivity to light

Sensitivity to light

A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings? a. The ropes are in the center of the wheel grooves b. The weights rest against the foot of the bed c. The weights are equal on each side d. The ropes are securely attached to the pins

The weights rest against the foot of the bed

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? Select all that apply. a. Massage over erythematous bony prominences b. Implement turning schedule every 4 hours c. Use pillows to keep hells off the bed surface d. Keep the client's skin dry with powder e. Minimize skin exposure to moisture

Use pillows to keep heels off the bed surface; minimize skin exposure to moisture

A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions? a. "I'll apply ice to my ankle today and tomorrow." b. "I'll rewrap my ankle starting from the knee down." c. "I'll bear weight on my ankle for 10 minutes every hour." d. "I'll put a heating pad on my ankle at bedtime tonight."

"I'll apply ice to my ankle today and tomorrow."

A nurse is discussing the differences between skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? a. "Skeletal traction has less risk for infection than skin traction." b. "Clients with skin traction have more mobility than those with skeletal traction." c. "Skeletal traction is more appropriate than skin traction for reducing a fracture." d. "Clients with skin traction have more discomfort than those with skeletal traction."

"Skeletal traction is more appropriate that skin traction for reducing a fracture."

A nurse is caring for an older adult client who had a stroke and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make? a. "So it seems that you feel responsible for what happened to your mother." b."Your mother will be fine. You shouldn't worry so much." c. "Why do you blame yourself? You could not have prevented the stroke." d. "You are not responsible for your mother's stroke, but many people in your situation feel this way."

"So it seems that you feel responsible for what happened to your mother."

A nurse is teaching an assistive personnel (AP) about the purpose of a footplate on the bed of a client whose leg is in Buck's traction Which of the following statements indicates the AP understands the teaching?" a. "The footplate works to anchor the traction." b. "The footplate helps to prevent foot drop." c. "The footplate keeps the client from sliding down in bed." d. "The footplate prevents pressure sores on the heel."

"The footplate helps to prevent foot drop."

A nurse is caring for an older adult client who had stroke and has left-sided weakness. The client's partner tells the nurse she is worried about the next steps of treatment for her partner. Which of the following responses should the nurse make? a. "We have begun plans to send your partner to a rehabilitation facility as soon as he is stable." b. "Your partner is too critical to consider what tomorrow will bring. Let's just concentrate on today." c. "Don't worry. Most clients like your partner start making progress after a few days of rest." d. "You will have to speak to the provider for that information. I can arrange that for you."

"We have begun plans to send your partner to a rehabilitation facility as soon as he is stable."

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect? a. A lucid period followed by an immediate loss of consciousness b. A change in the level of consciousness that develops over 48 hour c. Neurologic deficits that increase up to 2 weeks post-injury d. Cognitive perception that decreases over several months post-injury

A lucid period followed by an immediate loss of consciousness

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? a. Test the drainage for glucose b. Suction the nostril c. Notify the physician D. Ask the client to blow his nose

A. Test the drainage for glucose

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care? a. Ability to achieve independent transfer from bed to wheelchair b. Independent control of bladder and bowel function c. Use of a wheelchair with a chin or mouth stick d. Ability to self-feed with the use of adaptive equipement

Ability to self-feed with the use of adaptive equipment

A nurse is caring for a client who has an ICP reading of 40 mmHg. Which of the following findings should the nurse identify as a late sign of ICP? Select all that apply. a. Confusion b. Bradycardia c. Hypotension d. Nonreactive dilated pupils e. Slurred speech

Bradycardia; nonreactive dilated pupils

A nurse is teaching an older client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's traction. The nurse should include which of the following information in the teaching? a. Buck's traction will reduce the fracture b. Buck's traction will relieve muscle spasms c. Buck's traction will maintain alignment of the pins d. Buck's traction will allow supported movement of the extremity

Buck's traction will relieve muscle spasms

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has the following respiratory alterations? a. Kussmaul respirations b. Apneustic respirations c. Cheyne-Stokes respirations d. Stridor

Cheyne-Stokes respirations

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client's x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures? a. Impacted b. Transverse c. Comminuted d. Oblique

Comminuted

A nurse notes increasing edema in the calf of a client who has multiple fractures of the leg. The nurse should recognize that increasing edema is a manifestation of which of the following complications? a. Fat embolism syndrome b. Compartment syndrome c. Pulmonary embolism d. Malignant hyperthermia

Compartment syndrome

A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse? a. Slow the rate to 20 mL/hr b. Continue the rate at 125 mL/hr c. Slow the rate to 50 mL/hr d. Increase the rate to 250 mL/hr

Slow the rate to 50 mL/hr

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? a. Perform passive range of motion on each extremity b. Monitor the client's electrolyte levels c. Suction saliva from the client's mouth d. Record the client's intake and output

Suction saliva from the client's mouth

A nurse in an urgent care center is caring for a client who has a greenstick fracture of the forearm. The nurse should explain that which of the following injuries has occurred with a greenstick fracture? a. The bone is cracked lengthwise, but did not break all the way through b. Fragments of bone have splintered into the surrounding tissue c. The bone ends have been forced toward each other d. Sharp edge of the bone has broken through the skin

The bone is cracked lengthwise but did not break all the way through

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs? a. The client complains of pain b. The client develops a life threatening situation c. The client needs to have an x-ray of the femur performed d. The client has to be repositioned in bed

The client develops a life-threatening situation

A nurse is caring for a client who has a T4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? a. The client complains of a severe headache b. The client's bladder becomes distended c. The client's blood pressure becomes elevated d. The client states having nasal congestion

The client's bladder becomes distended

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? Select all that apply. a. Hypotension b. Polyuria c Hyperthermia d. Absence of bowel sounds E. Weakened gag reflex

a, c, d (hypotension, hyperthermia, absence of bowel sounds

A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which of the following responses should the nurse provide? a. Respite care allows the primary caregiver time away from day-to-day care responsibilities." b. "Respite care provides holistic support and care for a client who is terminally ill." c. "Respite care helps relieve pain and promote comfort." d. "Respite care is a continuation of psychological support after a family member dies."

"Respite care allows the primary caregiver time away from day-to-day care responsibilities."

A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client's family about organ donation. The client's spouse states that she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate? a. "There is such a shortage of organs in this country, so I think you should go ahead and consent to donate your spouse's organs." b. "What do you think your spouse would have wanted?" c. "Most religions support organ donation, so don't let that stand in your way." d. "Don't you think you will feel a little better about the situation if you donate your spouse's organs?"

"What do you think your spouse would have wanted?"

A nurse is caring for a client who was admitted to the facility in critical condition following a stroke. The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make? a. "Perhaps you could call your children to see how they are doing." b. "Don't worry. We'll take good care of your parent while you are gone." c. "You are feeling drawn in two separate directions." d. "There is nothing you can do here. You should go home to your children."

"You are feeling drawn in two separate directions."

A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is true regarding the postoperative placement of a prosthesis? a. "You will do special exercises in advance of getting your prosthesis." b."You will be fitted for your prosthesis at the time of surgery." c. "A special pressure dressing will remain on to cushion your prosthesis." d. "The prosthesis will be adjustable depending on what shoe you are wearing."

"You will do special exercises in advance of getting your prosthesis."

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? a. A reddened area over the sacrum b. Stiffness in the lower extremities c. Difficulty moving the upper extremities d. Difficulty hearing some types of sounds

A reddened area over the sacrum

A nurse in the ICU is caring for a client who has a severe traumatic brain injury and a cerebral perfusion pressure of 59 mmHg. Which of the following actions should the nurse take? a. Provide warming measures for the client b. Hyperextend the client's neck' c. Flex the client's hip d. Adjust the client's head of bed

Adjust the client's head of bed

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? Select all that apply. a. Assess legs for redness b. Apply elastic compression stockings c. Perform passive range of motion exercises d. Place pillows under the client's knees when in bed e. Massage the calves every shift

Assess legs for redness; apply elastic compression stockings; perform passive range of motion exercises

A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following actions should the nurse take? a. Provide the client with water to test the gag reflex b. Perform carotid massage c. Call 911 d. Drive the client to the nearest medical facility

Call 911

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III? a. Testing visual acuity b. Observing for facial symmetry c. Eliciting a gag reflex d. Checking the pupillary response to light

Checking the pupillary response to light

A nurse is teaching a class about providing emergency care for clients who have a sports-related injury. Which of the following information should the nurse include? a. Apply heat to the injury during the first 12 hours b. Maintain the affected extremity in a dependent position c. Perform passive range of motion to an injured joint d. Compress the injury for 24 hours

Compress the injury for 24 hours

A nurse is caring for a client who has sustained a traumatic brain injury (TBI). The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? a. Decreased level of consciousness b. Tachypnea c. Bilateral weakness of the extremities d. Hypotension

Decreased LOC

A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the laboratory findings should the nurse expect? a. Decreased serum calcium level b. Decreased level of serum lipids c. Decreased erythrocyte sedimentation rate (ESR) d. Increased platelet count

Decreased serum calcium level

A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign? a. Pinpoint pupils b. Jerking contractions of the head and neck c. Pronation of the arms d. Dorsiflexion of the great toe

Dorsiflexion of the great toe

A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization? a. Urge incontinence b. Dribbling of urine c. Weight gain d. Rectal distention

Dribbling of urine

A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching? a. Keep the prosthesis in direct contact with the residual limb b. Apply a moisturizing lotion or oil to the stump daily c. Dry the prosthesis socket completely before applying it to the limb d. Expect some skin irritation from the prosthesis

Dry the prosthesis socket completely before applying it to the limb

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? a. Cleanse the perineum from the back to the front b. Obtain an order for an indwelling urinary catheter c. Encourage fluid intake at and between meals d. Offer the client the bedpan every 2 hours

Encourage fluid intake at and between meals

A rehab nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? a. Inform the client that privileges are related to participation in therapy b. Limit visiting hours until the client begins to participate in therapy c. Allow the client to control the timing and frequency of the therapy d. Establish a plan of care with the client that sets attainable goals

Establish a plan of care with the client that sets attainable goals

A nurse is caring for a client who has multiple long bone fractures caused by a motor vehicle crash that happened 24 hours ago. The client tells the nurse he is short of breath and experiencing chest pain. The nurse should assess the client further for which of the following potential complications? a. Hypovolemic shock b. Fat embolism syndrome c. Compartment syndrome d. Venous thromboembolism

Fat embolism syndrome

A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? a. Serosanguineous drainage b. Mild erythema c. Warmth d. Fever

Fever

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure 198/110, pulse 82 bpm, respirations 24/min, and a temperature of 38.2C (100.8F). Which of the following neurologic disorders should the nurse suspect? a. Transient ischemic attack (TIA) b. Hemorrhagic stroke c. Thrombotic stroke d. Embolic stroke

Hemorrhagic stroke

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? a. Increased respiratory rate from 18 to 44/min b. Increased oral temperature from 36.6C (97.8F) to 37C (98.6F) c. Increased blood pressure from 112/68 to 120/72 d. Increased heart rate from 68 to 72 bpm

Increased respiratory rate from 18 to 14/min

During the assessment of a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following complications should the nurse suspect? a. Poor circulation b. Pressure from the cast c. Uneven cast drying d. Infection

Infection

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III? a. Instruct the client to look up and down without moving his head b. Observe the client's ability to smile and frown c. Have the client stand with eyes closed and touch his nose d. Ask the client to shrug his shoulders against passive resistance

Instruct the client to look up and down without moving his head

A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure (ICP). Which of the following medications should the nurse plan to administer? a. Albumin 25% b. Dextran 70 c. Hydroxyethyl glucose d. Mannitol 25%

Mannitol 25%

A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur. Which of the following interventions should the nurse include in the plan? a. Instruct the client to flex and extend the ankle twice daily b. Monitor the client's pedal pulses every hour c. Remove the weights every four hours d. Evaluate pressure points daily

Monitor the client's pedal pulses every hour

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first? a. Change in temperature of the toes b. Pallor of the toes c. Edema of the toes d. Inability to move toes

Pallor of the toes

A nurse is caring for a client who has had a spinal cord injury at the level of T2-T3. When planning care, the nurse should anticipate which of the following types of disability? a. Paresthesia b. Hemiplegia c. Quadriplegia d. Paraplegia

Paraplegia

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? a. Perform a neurovascular assessment b. Explain the discharge instructions to the client and parents c. Provide reassurance to the client and parents d. Apply an ice pack to the casted leg

Perform a neurovascular assessment

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fracture femur. Which of the following actions is the most important for the nurse to complete in the postoperative period? a. Medicate the client for pain b. Instruct the client on use of crutches c. Perform neurovascular checks of the extremity d. Direct the client to perform exercises of the ankles and toes

Perform neurovascular checks of the extremity

A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication? a. Pitting edema around the stump dressing b. Looseness of the stump dressing c. The dressing forms a cone shape over the stump d. Figure-eight wrapping around the stump

Pitting edema around the stump dressing

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? a. Poor impulse control b. Unable to discriminate words and letters c. Deficits in the right visual field d. Motor retardation

Poor impulse control

A nurse is caring for a client who experienced a femur fracture 8 hours ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first? a. Provide high-flow oxygen b. Check the client for a positive Chvostek's sign c. Administer an IV vasopressor d. Monitor the client for a headache

Provide high-flow oxygen

A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse to take to maintain privacy for the client? a. Close the door to the client's room b. Pull the curtains around the client's bed c. Ask family members to leave the room d. Use sterile drapes to cover the client

Pull the curtains around the client's bed

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in teaching? a. History of smoking b. Obesity c. History of hypertension d. Race

Race

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication? a. Reduce edema of the brain b. Provide fluid hydration c. Increase cell size of the brain d. Expand extracellular fluid volume

Reduce edema of the brain

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan? a. Apply restraints b. Administer opioids c. Darken the room d. Reduce stimuli

Reduce stimuli

A nurse is providing discharge teaching to a client who has a fracture of the right tibia and a fiberglass cast. Which of the following instructions should the nurse include in the teaching? a. Use a blow dryer on a moderate heat setting to dry the cast after showering b. Use a cotton swab to relieve itching under the cast c. Report any worsening or unrelieved pain d. Avoid moving the affected leg

Report any worsening or unrelieved pain

A nurse is caring for a client who has an order for balanced skeletal traction with a Thomas splint for the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint? a. Apply lotion to the skin under the edges of the splint b. Reposition the client to keep him from staying in the same position in bed c. Remove the weights for a few minutes each hour d. Apply a foot plate to the bed

Reposition the client to keep him from staying in the same position in bed

A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? a. Tachycardia b. Amnesia c. Hypotension d. Restlessness

Restlessness

A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? Select all that apply. a. Slight pain at the insertion site b. Serous drainage on the dressing c. Movement of the pin at the insertion site d. Elastic bandages secure around the traction ropes e. Minimal edema around the pin

Slight pain at the insertion site, serous drainage on the dressing, minimal edema around the pin