The nurse is assessing a child who has a fractured bone that has been pinned. There is caked blood and some purulent drainage in the pin area. Which of the following would be the best action for the nurse to take?
a. Clean the pin area with hydrogen peroxide solution.
b. Clean the area with soap and water.
c. Use hospital policy and, if not available, use alcohol on sterile 4 ยด 4's to clean the pin.
d. Report findings, and obtain a physician's order for pin-cleaning procedure.
D
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A Incorrect. Hydrogen peroxide solution is not an effective cleaning agent for the pin area for adults. Further studies need to be conducted to determine the best cleaning agent for children. Therefore, this would not be the best action for the nurse to take. The nurse's findings indicate an infection and should be reported first.
B Incorrect. There is insufficient evidence on which to recommend any single method of pin care. The nurse's findings indicate an infection and should be reported first.
C Incorrect. There is insufficient evidence on which to recommend any single method of pin care. The nurse's findings indicate an infection and should be reported first.
D Correct. The best action for the nurse to take after finding caked blood and some purulent drainage in the pin area is to report the findings, and obtain a physician's order for pin-cleaning procedure. Purulent drainage, redness, swelling, elevated temperature, odor, and complaints of pain are signs of infection.
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