A nurse cares for a client in skeletal traction. The nurse notes that the skin around the client's pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next?
a. Request a prescription to decrease the traction weight.
b. Apply an antibiotic ointment and a clean dressing.
c. Cleanse the area, scrubbing off the crusty areas.
d. Obtain a prescription to culture the drainage.
ANS: 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.
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