The client receives six IM injections over 3 days in the ventrogluteal site and the area is dark red and warm to the touch. What does the nurse implement next?
1. Continue to assess client for an infected IM injection site.
2. Collaborate with provider about potential allergic reaction.
3. Encourage client to perform range of motion to the muscle.
4. Check for a prescription to use a warm compress on the area.
1
1. The nurse continues to assess the client for an infected injection site because dark red, warm tissue is consistent with a soft tissue infection. The nurse evaluates the re-maining vital signs and leukocyte count, and assesses the site for induration, swelling, and drainage before collaborating with the provider on a revised plan of care.
2. The reddened area is more likely to be an infection than an allergy.
3 and 4. Encouraging range of motion and applying a warm compress seem like rea-sonable responses to this assessment data. Completing the nursing assessment is more important, because, depending on the outcome of the assessment, these interventions can be unsuitable for the client.
You might also like to view...
An older client is receiving corticosteroid therapy to treat asthma. The nurse knows that
A) inhaled medications cause less severe adverse effects than systemic forms. B) there is a risk of hyperkalemia. C) the client may develop hypoglycemia. D) the client may experience hypotension.
The nurse is caring for an older adult who has been admitted to an acute care hospital for treatment of a fractured femur
The family expresses concern about the patient's pending transfer to a subacute care facility. What response by the nurse is best? a. "Acute care facilities lack the long-term physical therapy support your dad re-quires." b. "Your dad will be much happier in a more serene, private environment." c. "The subacute facility will focus on help-ing your dad maintain his independence." d. "Insurance, including Medicare, will cover only a limited amount of time here."
The nurse has completed a teaching session for a client with a tracheostomy. Documentation of the session should include what information?
1. Diagnosed learning needs 2. Supplies required 3. Client outcomes 4. Need for additional teaching 5. Topics taught
A public health nurse understands that the emergence of new infectious diseases is influenced by the:
a. Increased availability of immunizations b. Globalization of food supplies c. Decreased use of child care facilities d. Creation of sanitation systems in third world countries