The nurse prepares to apply moist heat to the client who has a temperature of 39° C and an open draining incision on the hand with limited range of motion in the fingers
Which is the most im-portant intervention for the nurse to implement before applying moist heat to the hand? 1. Apply an ice pack to the client's hand.
2. Encase the hand in a sterile plastic bag.
3. Collaborate with provider for a culture.
4. Notify the provider of client assessment.
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4. The most important nursing intervention is for the nurse to inform the provider about the client's assessment to justify collaboration for a wound culture because the provider is unlikely to approve the request without supporting assessment data. The nurse's preliminary conclusion is reasonable because a client with a temperature at 39° C, an open draining wound, and limited range of motion has clinical indicators consistent with infection. Applying moist heat potentially benefits the client by im-proving regional perfusion and cell metabolism, improving waste removal from the area, alleviating edema, and improving immune function at the site. As long as the client's neurovascular assessment is within normal limits and the client does not have a history of peripheral vascular disease, the moist heat therapy should facilitate wound healing.
1. Cold therapy is contraindicated for the client with an open draining incision and stiff joints because cold causes vessels to vasoconstrict and thereby limits regional perfusion and delivery of oxygen and nutrients to compromised tissue and increases joint stiffness.
2. The nurse avoids encasing the hand in a sterile bag for therapy; because the wound is draining, the nurse can use clean technique.
3. The second most important action is to collaborate for a wound culture because antimicrobial therapy should not begin until the culture is obtained; administering the antimicrobial before the culture is obtained can alter the results of the culture.
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