The nurse is teaching the client about pin site care. Which does the nurse include in client teaching for self-care at home?
1. Use swabs to clean from periphery toward each pin.
2. Wrap the pins with sterile gauze saturated in peroxide.
3. Cover pin sites with dry sterile gauze or leave open to air.
4. Use one cotton swab to clean all of the pins with peroxide.
3
3, 1, and 2. The nurse teaches the client to cleanse each pin with an individual swab using prescribed antiseptic. The nurse also instructs the client to start at the insertion site cleansing toward the periphery without changing direction because this unidirec-tional movement prevents site contamination. After cleansing and passive drying, the nurse directs the client to cover the insertion sites with dry, sterile gauze or to leave them open to room air depending on the surgeon's instructions. The advantage of us-ing gauze is protection of the site with a gauze barrier; however, the gauze must re-main dry.
4. The nurse cleanses each site with a fresh, cleansing swab to prevent cross-contamination from potential pin site infections.
You might also like to view...
A homeless client is being admitted to the acute medical–surgical unit in a hospital. The nurse predicts which of the following as health risks for this client? Standard Text: Select all that apply
1. Improper nutrition 2. Lack of social support 3. Sleep needs usually met 4. Increased susceptibility to infection 5. Poor personal hygiene
The nurse assesses the reproductive system of an older adult. Which of the following questions should the nurse consider including in the interview?
A) "Do you ever have secretions, blood, or other discharge from your genitals?" B) "Does your partner have satisfying orgasms?" C) "When was the last time you had sexual intercourse?" D) "With whom do you have sexual intercourse?"
What do families desire from hospice care?
1. Continuity of care. 2. Comfort for the dying family member. 3. Autonomy for family members. 4. Case management.
The nurse is having a conversation with an adolescent regarding the need for sleep. The adolescent states that it is common to stay up with friends several nights a week. Which nursing action should the nurse take?
a. Discuss with the adolescent's parent staying up with friends and the need for sleep. b. Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness. c. This is a normal occurrence for adolescents and action is not required. d. Explore the reason for staying up late with friends several nights a week.