When inspecting the skeletal pin sites, you note that the skin is reddened for an inch aroundthe pin on both the medial and lateral left leg
What does this finding indicate, and whataction will you take?
• Slight redness would be expected, but redness that extends for a 1-inch radius from the pin
indicates a possible infection.
• Obtain wound cultures as needed. Be sure to obtain cultures before applying any cleansers or
antibiotics.
• Perform pin care according to physician preference or institutional policy. A chlorhexidine 2 mg/mL
solution, or normal saline, may be used for cleaning.
• Use sterile technique.
• Check white blood cell (WBC) count results; note trends and look for increase.
• Monitor vital signs (VS), including Spo2.
• Frequently an antibiotic ointment is placed around the pin sites. The decision depends on
prescriber preference. Neosporin produces a higher risk for allergic reactions because it contains
several different antibiotics: bacitracin, neomycin, and polymyxin B. Frequently bacitracin is used.
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A 30-year-old woman with a history of mitral valve problems states that she has been "very tired." She has started waking up at night and feels like her "heart is pounding."
During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area, the nurse also auscultates a blowing, swishing sound right after the S1. These findings would be most consistent with: a. Heart failure. b. Aortic stenosis. c. Pulmonary edema. d. Mitral regurgitation.
What must nurses do to fulfill a collaborative role?
1. Graduate with at least a baccalaureate degree. 2. Assume increased authority in practice areas. 3. Redesign unit policies to allow collaboration. 4. Lobby state boards of nursing to approve this collaborative role.
Which is the most likely reason that type 2 diabetes mellitus is often difficult to diagnose in older adults?
a. Presenting symptoms occur very quickly. b. The disease rarely occurs in older adults. c. The classic symptoms may not be present in older adults. d. There are no recognizable symptoms; it is a "silent killer."
At the time of admission, a patient with a terminal illness tells the nurse that her daughter will be allowed to make health-related decisions if she becomes incapacitated. What should the nurse realize this patient is specifically describing?
1. healthcare surrogate 2. living will 3. durable power of attorney 4. advance directive