A nurse is bathing a client who had a bone marrow aspiration from the right iliac crest 5 days ago. Which of the following findings would be of concern to the nurse?
A)
The needle aspiration site is ecchymotic.
B)
The client complains of moderate pain in the right iliac crest.
C)
The needle insertion site is scabbed over and without drainage.
D)
The client is doing isometric leg exercises.
B
Explanation:
A)
Continued pain after 3 to 4 days is abnormal and should be reported. Ecchymosis of the site would be normal at 5 days. Isometric exercises would not be contraindicated.
Analysis
Evaluation
Physiological Integrity: Reduction of Risk Potential
B)
Continued pain after 3 to 4 days is abnormal and should be reported. Ecchymosis of the site would be normal at 5 days. Isometric exercises would not be contraindicated.
Analysis
Evaluation
Physiological Integrity: Reduction of Risk Potential
C)
Continued pain after 3 to 4 days is abnormal and should be reported. Ecchymosis of the site would be normal at 5 days. Isometric exercises would not be contraindicated.
Analysis
Evaluation
Physiological Integrity: Reduction of Risk Potential
D)
Continued pain after 3 to 4 days is abnormal and should be reported. Ecchymosis of the site would be normal at 5 days. Isometric exercises would not be contraindicated.
Analysis
Evaluation
Physiological Integrity: Reduction of Risk Potential
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