A client is in skeletal traction. With the nurse's assessment, it is noted that the pins appear red, swollen, and there is purulent drainage. What action does the nurse take first?
Cleanse the skin around the pins.
Collect a culture of the purulent fluid.
Administer an antibiotic.
Instruct the client to complete exercises of the affected extremity.
The Correct Answer is A
Choice A reason: Cleansing the skin around the pins is the action that the nurse takes first, because it is the most urgent and relevant action. Cleansing the skin around the pins is a procedure that involves removing any dirt, debris, or secretions from the pin sites, which can help prevent or treat infection, inflammation, or pain. Cleansing the skin around the pins is a priority intervention, as it can reduce the risk of complications, such as osteomyelitis, sepsis, or pin loosening.
Choice B reason: Collecting a culture of the purulent fluid is not the action that the nurse takes first, because it is not the most urgent and relevant action. Collecting a culture of the purulent fluid is a procedure that involves obtaining a sample of the pus from the pin sites and sending it to the laboratory for analysis, which can help identify the type and source of infection. Collecting a culture of the purulent fluid is an important intervention, but it should be done after cleansing the skin around the pins, and with a medical order and a sterile technique.
Choice C reason: Administering an antibiotic is not the action that the nurse takes first, because it is not the most urgent and relevant action. Administering an antibiotic is a procedure that involves giving the client an antimicrobial agent, which can help fight or prevent infection. Administering an antibiotic is an important intervention, but it should be done after cleansing the skin around the pins, and with a medical order and a proper route.
Choice D reason: Instructing the client to complete exercises of the affected extremity is not the action that the nurse takes first, because it is not the most urgent and relevant action. Instructing the client to complete exercises of the affected extremity is a procedure that involves teaching the client how to move and strengthen the muscles and joints of the limb in traction, which can help prevent or treat atrophy, contracture, or thrombosis. Instructing the client to complete exercises of the affected extremity is an important intervention, but it should be done after cleansing the skin around the pins, and with a medical order and a safe technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: "Tell me about what medications you are taking." is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Medications are part of the physical or pharmacological assessment, which focuses on the type, dose, frequency, and effectiveness of the drugs that the client is taking for rheumatoid arthritis. Medications may have some psychosocial implications, such as side effects, costs, or adherence, but they are not the main focus of the psychosocial assessment.
Choice B reason: "What physical limitations are you experiencing?" is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Physical limitations are part of the functional or mobility assessment, which focuses on the range of motion, strength, endurance, and coordination of the joints and muscles that are affected by rheumatoid arthritis. Physical limitations may have some psychosocial implications, such as pain, disability, or dependence, but they are not the main focus of the psychosocial assessment.
Choice C reason: "How does this impact your role in your family?" is the most appropriate statement by the nurse, because it is related to the psychosocial assessment. Role in the family is part of the social or relational assessment, which focuses on the interactions, responsibilities, and expectations of the client and their family members in relation to rheumatoid arthritis. Role in the family may have significant psychosocial implications, such as role changes, role conflicts, role strain, or role loss, which can affect the client's selfesteem, identity, and coping.
Choice D reason: "What therapies are you using to reduce swelling?" is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Therapies are part of the physical or nonpharmacological assessment, which focuses on the modalities, techniques, or devices that the client is using to manage the symptoms of rheumatoid arthritis. Therapies may have some psychosocial implications, such as availability, accessibility, or preference, but they are not the main focus of the psychosocial assessment.
Correct Answer is C
Explanation
Choice A reason: Culturing the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Culturing the wound is a procedure that involves collecting a sample of the wound drainage and sending it to the laboratory for analysis, which can help identify the type and source of infection. Culturing the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a sterile technique.
Choice B reason: Applying topical ointment to the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Applying topical ointment to the wound is a procedure that involves applying a medication or a dressing to the wound site, which can help prevent or treat infection, inflammation, or pain. Applying topical ointment to the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a clean technique.
Choice C reason: Inspecting the wound and assessing the drainage is the nurse's priority assessment for this client, because it is the most urgent and relevant action. Inspecting the wound and assessing the drainage is a process that involves observing and measuring the wound site and the wound exudate, which can reveal the presence and severity of infection, injury, or healing. Inspecting the wound and assessing the drainage is an essential assessment, as it can guide the diagnosis, treatment, and evaluation of the client's condition.
Choice D reason: Calling the provider to initiate antibiotics is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Calling the provider to initiate antibiotics is a communication that involves reporting the client's situation and requesting a prescription for an antimicrobial agent, which can help fight or prevent infection. Calling the provider to initiate antibiotics is an important communication, but it should be done after inspecting the wound and assessing the drainage, and with the necessary data and documentation.
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