The nurse notes that the skin around the client's skeletal traction pin site is swollen, red, and crusty, with dried drainage. Which is the nurse's priority intervention?
a. Decrease the traction weight.
b. Apply a new dressing.
c. Cleanse the area, scrubbing off the crusty areas.
d. Culture the drainage.
D
These clinical manifestations indicate inflammation and possible infection. Infected pin sites can lead to osteomyelitis and should be treated immediately. The nurse should obtain a culture and assess vital signs. The provider should be notified. By decreasing the traction weight, applying a new dressing, or cleansing the area, the infection cannot be significantly treated.
You might also like to view...
A student nurse questions the nursing instructor about the constant information being relayed in reports about the client's method of payment
The student reports not understanding why this is being emphasized, as it is not the real focus of the nurse. What response by the nursing instructor is indicated? A) "Since pay status is a concern of the client, it must be considered by nurses as well." B) "Understanding healthcare reimbursement is important for nurses to best be able to manage resources." C) "That information is just intended to be relayed to the case manager." D) "We listen to that information so we understand how many days the client will be allowed to remain in the hospital."
A nurse is caring for an African American patient with severe hemophilia A who has been admitted for bleeding into the knee joint. The prescriber has ordered intravenous factor VIIa [NovoSeven RT]
A nursing student wants to know why this patient is not receiving factor VIII. Which statement by the nurse is correct? a. "Factor VIIa is stronger than factor VIII and will work faster." b. "Factor VIII is used for prophylaxis, and factor VIIa is used for acute episodes." c. "Factor VIIa is used when patients devel-op antibodies against factor VIII." d. "Factor VIIa provides immune tolerance therapy so that factor VIII will be more effective."
A patient is transferred to a rehabilitation-oriented residential mental health program. Which expected outcome applies to the new care setting?
a. Symptom relief b. Improved functioning c. No harm to self or others d. Attain optimal quality of life
A patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take?
a. Remind the patient about the need to drink 1000 mL of fluids daily. b. Obtain a midstream urine specimen for culture and sensitivity testing. c. Teach the patient to take the prescribed Bactrim for at least 3 more days. d. Suggest that the patient use acetaminophen (Tylenol) to treat the symptoms.